Evidence was obtained from two principal sources: scientific evidence and opinion-based evidence. Practice guidelines for central venous access: A report by the American Society of Anesthesiologists Task Force on Central Venous Access. Reduced colonization and infection with miconazole-rifampicin modified central venous catheters: A randomized controlled clinical trial. The procedure to place a femoral central line is as follows: You will have to lie down on your back for this procedure. A multitiered strategy of simulation training, kit consolidation, and electronic documentation is associated with a reduction in central lineassociated bloodstream infections. The consultants and ASA members agree that static ultrasound may also be used when the subclavian or femoral vein is selected. See 2017 Food and Drug Administration warning on chlorhexidine allergy. Proper maintenance of CVCs includes disinfection of catheter hubs, connectors, and injection ports and changing dressings over the site every two days for gauze . Society for Pediatric Anesthesia Winter Meeting, April 17, 2010, San Antonio, Texas; Society of Cardiovascular Anesthesia 32nd Annual Meeting, April 25, 2010, New Orleans, Louisiana; and International Anesthesia Research Society Annual Meeting, May 22, 2011, Vancouver, British Columbia, Canada. Efficacy of silver-coating central venous catheters in reducing bacterial colonization. The consultants and ASA members agree with the recommendation to use catheters coated with antibiotics or a combination of chlorhexidine and silver sulfadiazine based on infectious risk and anticipated duration of catheter use for selected patients. Address correspondence to the American Society of Anesthesiologists: 1061 American Lane, Schaumburg, Illinois 60173. trace the line from its insertion towards the heart. 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. Ultrasound validation of maneuvers to increase internal jugular vein cross-sectional area and decrease compressibility. Trendelenburg position does not increase cross-sectional area of the internal jugular vein predictably. Category A: RCTs report comparative findings between clinical interventions for specified outcomes. Complications and failures of subclavian-vein catheterization. Level 1: The literature contains nonrandomized comparisons (e.g., quasiexperimental, cohort [prospective or retrospective], or case-control research designs) with comparative statistics between clinical interventions for a specified clinical outcome. Matching Michigan: A 2-year stepped interventional programme to minimise central venous catheter-blood stream infections in intensive care units in England. Impact of ultrasonography on central venous catheter insertion in intensive care. Catheter maintenance consists of (1) determining the optimal duration of catheterization, (2) conducting catheter site inspections, (3) periodically changing catheters, and (4) changing catheters using a guidewire instead of selecting a new insertion site. The effect of hand hygiene compliance on hospital-acquired infections in an ICU setting in a Kuwaiti teaching hospital. In 2017, the ASA Committee on Standards and Practice Parameters requested that these guidelines be updated. 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 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. 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. Comparison of the effect of the Trendelenburg and passive leg raising positions on internal jugular vein size in critically ill patients. Within the text of these guidelines, literature classifications are reported for each intervention using the following: Category A level 1, meta-analysis of randomized controlled trials (RCTs); Category A level 2, multiple RCTs; Category A level 3, a single RCT; Category B level 1, nonrandomized studies with group comparisons; Category B level 2, nonrandomized studies with associative findings; Category B level 3, nonrandomized studies with descriptive findings; and Category B level 4, case series or case reports. ( 21460264) Transition to a PICC line for long-term central access. Multimodal interventions for bundle implementation to decrease central lineassociated bloodstream infections in adult intensive care units in a teaching hospital in Taiwan, 20092013. Effectiveness of a programme to reduce the burden of catheter-related bloodstream infections in a tertiary hospital. Chlorhexidine-related refractory anaphylactic shock: A case successfully resuscitated with extracorporeal membrane oxygenation. A randomized trial on chlorhexidine dressings for the prevention of catheter-related bloodstream infections in neutropenic patients. Methods for confirming that the catheter or thin-wall needle resides in the vein include, but are not limited to, ultrasound, manometry, or pressure-waveform analysis measurement. Comparison of three techniques for internal jugular vein cannulation in infants. Evidence categories refer specifically to the strength and quality of the research design of the studies. For these guidelines, central venous access is defined as placement of a catheter such that the catheter is inserted into a venous great vessel. Central Line Insertion Care Team Checklist Instructions Operator Requirements: Specify minimum requirements. The purposes of these guidelines are to (1) provide guidance regarding placement and management of central venous catheters; (2) reduce infectious, mechanical, thrombotic, and other adverse outcomes associated with central venous catheterization; and (3) improve management of arterial trauma or injury arising from central venous catheterization. Significant reduction of central-line associated bloodstream infections in a network of diverse neonatal nurseries. Ultrasound as a screening tool for central venous catheter positioning and exclusion of pneumothorax. These evidence categories are further divided into evidence levels. The rapid atrial swirl sign for assessing central venous catheters: Performance by medical residents after limited training. The needle was exchanged over the wire for an arterial . Do not force the wire; it should slide smoothly. The needle insertion path: Insert procedural needles (local anesthetic, finder, and introducer needles) 2 to 4 cm inferior to the inguinal ligament, 1 cm medial to the femoral artery, at a 45 to 60 angle into the skin, and aim toward the umbilicus. 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 . Nosocomial sepsis: Evaluation of the efficacy of preventive measures in a level-III neonatal intensive care unit. Netcare Antimicrobial Stewardship and Infection Prevention Study Alliance. The bubble study: Ultrasound confirmation of central venous catheter placement. Stepwise introduction of the Best Care Always central-lineassociated bloodstream infection prevention bundle in a network of South African hospitals. Assessment of a central lineassociated bloodstream infection prevention program in a burn-trauma intensive care unit. Central venous catheters revisited: Infection rates and an assessment of the new fibrin analysing system brush. A summary of recommendations can be found in appendix 1. Publications identified by task force members were also considered. Reducing the rate of catheter-associated bloodstream infections in a surgical intensive care unit using the Institute for Healthcare Improvement Central Line Bundle. = 100%; (5) selection of antiseptic solution for skin preparation = 100%; (6) catheters with antibiotic or antiseptic coatings/impregnation = 68.5%; (7) catheter insertion site selection (for prevention of infectious complications) = 100%; (8) catheter fixation methods (sutures, staples, tape) = 100%; (9) insertion site dressings = 100%; (10) catheter maintenance (insertion site inspection, changing catheters) = 100%; (11) aseptic techniques using an existing central line for injection or aspiration = 100%; (12) selection of catheter insertion site (for prevention of mechanical trauma) = 100%; (13) positioning the patient for needle insertion and catheter placement = 100%; (14) needle insertion, wire placement, and catheter placement (catheter size, type) = 100%; (15) guiding needle, wire, and catheter placement (ultrasound) = 100%; (16) verifying needle, wire, and catheter placement = 100%; (17) confirmation of final catheter tip location = 89.5%; and (18) management of trauma or injury arising from central venous catheterization = 100%. Anesthesia was achieved using 1% lidocaine. Images in cardiovascular medicine: Percutaneous retrieval of a lost guidewire that caused cardiac tamponade. For studies that report statistical findings, the threshold for significance is P < 0.01. These updated guidelines were developed by means of a five-step process. Your physician will locate the femoral pulse with their nondominant hand. The authors thank David G. Nickinovich, Ph.D., Nickinovich Research and Consulting, Inc. (Bellevue, Washington) for his service as methodology consultant for this task force and his invaluable contributions to the original version of these Guidelines. The consultants are equivocal and ASA members agree that when using the catheter-over-the-needle technique, confirmation that the wire resides in the vein may not be needed (1) if the catheter enters the vein easily and manometry or pressure-waveform measurement provides unambiguous confirmation of venous location of the catheter and (2) if the wire passes through the catheter and enters the vein without difficulty. Posterior cerebral infarction following loss of guide wire. Always ensure target for venous cannulation is visualized and guidewire is placed correctly prior to dilation: 1) Compression of target vessel 2) Non-pulsatile dark blood return (unless on 100%FiO2, may be brighter red) 3) US visualization or needle and wire 4) can use pressure tubing and angiocath to confirm CVP or obtain venous O2 sat tip too high: proximal SVC. Inferred findings are given a directional designation of beneficial (B), harmful (H), or equivocal (E). First, consensus was reached on the criteria for evidence. Randomized, controlled clinical trial of point-of-care limited ultrasonography assistance of central venous cannulation: The Third Sonography Outcomes Assessment Program (SOAP-3) Trial. 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 ). . Incidence of mechanical complications of central venous catheterization using landmark technique: Do not try more than 3 times. Antiseptic-bonded central venous catheters and bacterial colonisation. 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. Microbiological evaluation of central venous catheter administration hubs. 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. Once the central line is in place, remove the wire. 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. Literature Findings. Algorithm for central venous insertion and verification. Literature exclusion criteria (except to obtain new citations): For the systematic review, potentially relevant clinical studies were identified via electronic and manual searches. Accepted studies from the previous guidelines were also rereviewed, covering the period of January 1, 1971, through June 31, 2011. The authors declare no competing interests. Aseptic insertion of central venous lines to reduce bacteraemia: The central line associated bacteraemia in NSW intensive care units (CLAB ICU) collaborative. Is traditional reading of the bedside chest radiograph appropriate to detect intraatrial central venous catheter position? Ultrasound for localization of central venous catheter: A good alternative to chest x-ray? A delayed diagnosis of a retained guidewire during central venous catheterisation: A case report and review of the literature. Each pertinent outcome reported in a study was classified by evidence category and level and designated as beneficial, harmful, or equivocal. Femoral vein cannulation performed by residents: A comparison between ultrasound-guided and landmark technique in infants and children undergoing cardiac surgery. Although catheter removal is not addressed by these guidelines (and is not typically performed by anesthesiologists), the risk of venous air embolism upon removal is a serious concern. Safety of central venous catheter change over guidewire for suspected catheter-related sepsis: A prospective randomized trial. 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. Comparison of needle insertion and guidewire placement techniques during internal jugular vein catheterization: The thin-wall introducer needle technique. The epidemiology, antibiograms and predictors of mortality among critically-ill patients with central lineassociated bloodstream infections. Effects of the Trendelenburg position and positive end-expiratory pressure on the internal jugular vein cross-sectional area in children with simple congenital heart defects. Comparison of silver-impregnated with standard multi-lumen central venous catheters in critically ill patients. The consultants and ASA members strongly agree with the recommendation to select catheter size (i.e., outside diameter) and type based on the clinical situation and skill/experience of the operator. These recommendations may be adopted, modified, or rejected according to clinical needs and constraints and are not intended to replace local institutional policies. Opinion surveys were developed by the task force to address each clinical intervention identified in the document. Catheter-associated bloodstream infection in the pediatric intensive care unit: A multidisciplinary approach. The journey to zero central catheter-associated bloodstream infections: Culture change in an intensive care unit. 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. Biopatch: A new concept in antimicrobial dressings for invasive devices. 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. 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. Reduction of catheter-related bloodstream infections through the use of a central venous line bundle: Epidemiologic and economic consequences. Strict hand hygiene and other practices shortened stays and cut costs and mortality in a pediatric intensive care unit. Preparation of these updated guidelines followed a rigorous methodological process. Guidewire catheter change in central venous catheter biofilm formation in a burn population. A prospective, randomized study in critically ill patients using the Oligon Vantex catheter. 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. Chlorhexidine-impregnated dressings and prevention of catheter-associated bloodstream infections in a pediatric intensive care unit. Allergy to chlorhexidine: Beware of the central venous catheter. Although observational studies report that Trendelenburg positioning (i.e., head down from supine) increases the right internal jugular vein diameter or cross-sectional area in adult volunteers (Category B2-B evidence),157161 findings are equivocal for studies enrolling adult patients (Category B2-E evidence).158,162164 Observational studies comparing the Trendelenburg position and supine position in pediatric patients report increased right internal jugular vein diameter or cross-sectional area (Category B2-B evidence),165167 and one observational study of newborns reported similar findings (Category B2-B evidence).168 The literature is insufficient to evaluate whether Trendelenburg positioning improves insertion success rates or decreases the risk of mechanical complications. Support was provided solely by the American Society ofAnesthesiologists (Schaumburg, Illinois). New York State Regional Perinatal Care Centers. Literature Findings. Reducing PICU central lineassociated bloodstream infections: 3-year results. Level 2: The literature contains noncomparative observational studies with associative statistics (e.g., correlation, sensitivity, and specificity). subclavian vein (left or right) assessing position. 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. Survey Findings. 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. 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. 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. The lack of sufficient scientific evidence in the literature may occur when the evidence is either unavailable (i.e., no pertinent studies found) or inadequate. Fifth, all available information was used to build consensus to finalize the guidelines. The literature is insufficient to evaluate outcomes associated with the routine use of intravenous prophylactic antibiotics. Impact of a national multimodal intervention to prevent catheter-related bloodstream infection in the ICU: The Spanish experience. When available, category A evidence is given precedence over category B evidence for any particular outcome. Maintaining and sustaining the On the CUSP: Stop BSI model in Hawaii. Prevention of central venous catheter-related infections by using maximal sterile barrier precautions during insertion. The consultants strongly agree and ASA members agree with the recommendation to not use catheters containing antimicrobial agents as a substitute for additional infection precautions. 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. Palpating the femoral pulse throughout the procedure, the introducer needle was inserted into the femoral artery. Arterial misplacement of large-caliber cannulas during jugular vein catheterization: Case for surgical management. The impact of central line insertion bundle on central lineassociated bloodstream infection. Level 4: The literature contains case reports. American Society of Anesthesiologists Task Force on Central Venous A. The consultants and ASA members agree with the recommendation to use an assistant during placement of a central venous catheter. These guidelines have been endorsed by the Society of Cardiovascular Anesthesiologists and the Society for Pediatric Anesthesia. Survey Findings. Literature Findings. In addition, practice guidelines developed by the American Society of Anesthesiologists (ASA) are not intended as standards or absolute requirements, and their use cannot guarantee any specific outcome. The consultants and ASA members both strongly agree with the recommendation to minimize the number of needle punctures of the skin. The syringe was removed and a guidewire was advanced through the needle into the femoral artery. Ultrasound evaluation of central veinsin the intensive care unit: Effects of dynamic manoeuvres. For membership respondents, the survey rate of return was 8% (n = 393 of 5,000) members. Prevention of catheter-related infections by silver coated central venous catheters in oncological patients. Aseptic techniques using an existing central venous catheter for injection or aspiration consist of (1) wiping the port with an appropriate antiseptic, (2) capping stopcocks or access ports, and (3) use of needleless catheter connectors or access ports. 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. The impact of a quality improvement intervention to reduce nosocomial infections in a PICU. tip should be at the cavoatrial junction. Benefits of minocycline and rifampin-impregnated central venous catheters: A prospective, randomized, double-blind, controlled, multicenter trial. Advance the guidewire through the needle and into the vein. National Association of Childrens Hospitals and Related Institutions Pediatric Intensive Care Unit Central LineAssociated Bloodstream Infection Quality Transformation Teams. The consultants and ASA members strongly agree with the recommendation to use a chlorhexidine-containing solution for skin preparation in adults, infants, and children. document the position of the line. 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. Transthoracic echocardiographic guidance for obtaining an optimal insertion length of internal jugular venous catheters in infants. In most instances, central venous access with ultrasound guidance is considered the standard of care. Ultrasound guidance outcomes were pooled using risk or mean differences (continuous outcomes) for clinical relevance. R: A Language and Environment for Statistical Computing. Confirmation of venous placement for dialysis catheters should be done by venous blood gas prior to the initial dialysis run. 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. The policy of the American Society of Anesthesiologists (ASA) Committee on Standards and Practice Parameters is to update practice guidelines every 5 yr. Methods for confirming the position of the catheter tip include chest radiography, fluoroscopy, or point-of-care transthoracic echocardiography or continuous electrocardiography.