For neonates, the consultants and ASA members agree with the recommendation to determine the use of transparent or sponge dressings containing chlorhexidine based on clinical judgment and institutional protocol. 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. (Committee Chair), Chicago, Illinois; Stephen M. Rupp, M.D. Metasens: Advanced Statistical Methods to Model and Adjust for Bias in Meta-Analysis. Sensitivity to effect measure was also examined. The consultants and ASA members agree that static ultrasound may also be used when the subclavian or femoral vein is selected. An evaluation with ultrasound. 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. Chlorhexidine-impregnated dressing for prevention of colonization of central venous catheters in infants and children: A randomized controlled study. Fourth, additional opinions were solicited from random samples of active ASA members. Ultrasound-guided central venous cannulation is superior to quick-look ultrasound and landmark methods among inexperienced operators: A prospective randomized study. Impact of a prevention strategy targeted at vascular-access care on incidence of infections acquired in intensive care. An RCT comparing maximal barrier precautions (i.e., mask, cap, gloves, gown, large full-body drape) with a control group (i.e., gloves and small drape) reports equivocal findings for reduced colonization and catheter-related septicemia (Category A3-E evidence).72 A majority of observational studies reporting or with calculable levels of statistical significance report that bundles of aseptic protocols (e.g., combinations of hand washing, sterile full-body drapes, sterile gloves, caps, and masks) reduce the frequency of central lineassociated or catheter-related bloodstream infections (Category B2-B evidence).736 These studies do not permit assessing the effect of any single component of a bundled protocol on infection rates. The epidemiology, antibiograms and predictors of mortality among critically-ill patients with central lineassociated bloodstream infections. Antimicrobial durability and rare ultrastructural colonization of indwelling central catheters coated with minocycline and rifampin. Avoiding complications and decreasing costs of central venous catheter placement utilizing electrocardiographic guidance. Elective central venous access procedures, Emergency central venous access procedures, Any setting where elective central venous access procedures are performed, Providers working under the direction of anesthesiologists, Individuals who do not perform central venous catheterization, Selection of a sterile environment (e.g., operating room) for elective central venous catheterization, Availability of a standardized equipment set (e.g., kit/cart/set of tools) for central venous catheterization, Use of a trained assistant for central venous catheterization, Use of a checklist for central venous catheter placement and maintenance, Washing hands immediately before placement, Sterile gown, gloves, mask, cap for the operators, Shaving hair versus clipping hair versus no hair removal, Skin preparation with versus without alcohol, Antibiotic-coated catheters versus no coating, Silver-impregnated catheters versus no coating, Heparin-coated catheters versus no coating, Antibiotic-coated or silver-impregnated catheter cuffs, Selecting an insertion site that is not contaminated or potentially contaminated (e.g., burned or infected skin, a site adjacent to a tracheostomy site), Long-term versus short-term catheterization, Frequency of assessing the necessity of retaining access, Frequency of insertion site inspection for signs of infection, At specified time intervals versus no specified time intervals, One specified time interval versus another time interval, Changing over a wire versus a new catheter at a new site, Injecting or aspirating using an existing central venous catheter, Aseptic techniques (e.g., wiping port with alcohol). 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). Central venous line placement is typically performed at four sites in the body: . Perform central venous catheterization in an environment that permits use of aseptic techniques, Ensure that a standardized equipment set is available for central venous access, Use a checklist or protocol for placement and maintenance of central venous catheters, Use an assistant during placement of a central venous catheter#. R: A Language and Environment for Statistical Computing. The effect of hand hygiene compliance on hospital-acquired infections in an ICU setting in a Kuwaiti teaching hospital. Antiseptic-bonded central venous catheters and bacterial colonisation. 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. Ultrasonography: A novel approach to central venous cannulation. A retrospective observational study reports that manometry can detect arterial punctures not identified by blood flow and color (Category B3-B evidence).213 The literature is insufficient to address ultrasound, pressure-waveform analysis, blood gas analysis, blood color, or the absence of pulsatile flow as effective methods of confirming catheter or thin-wall needle venous access. Location of the central venous catheter tip with bedside ultrasound in young children: Can we eliminate the need for chest radiography? Anaphylactic shock induced by an antiseptic-coated central venous [correction of nervous] catheter. . 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. Risk factors for catheter-related bloodstream infection: A prospective multicenter study in Brazilian intensive care units. 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. Release pressure but keep fingers in place over femoral pulse Insert needle at a 45 deg angle medial to femoral pulse If unable to palpate femoral pulse (and ultrasound unavailable): Palpate ASIS and midpoint of the pubic symphysis, imagine a line between them Femoral artery lies at junction of medial and middle thirds of this line Prospective randomised trial of povidoneiodine, alcohol, and chlorhexidine for prevention of infection associated with central venous and arterial catheters. The accuracy of electrocardiogram-controlled central line placement. Methods for confirming that the catheter is still in the venous system after catheterization and before use include manometry or pressure-waveform measurement. I have read and accept the terms and conditions. Simplified point-of-care ultrasound protocol to confirm central venous catheter placement: A prospective study. When an equal number of categorically distinct responses are obtained, the median value is determined by calculating the arithmetic mean of the two middle values. Findings from these RCTs are reported separately as evidence. - right femoral line: find the arterial pulse and enter the skin 1 cm medial to this, at a 45 angle to the vertical and heading parallel to the artery. Ties are calculated by a predetermined formula. Suggestions for minimizing such risk are those directed at raising central venous pressure during and immediately after catheter removal and following a defined nursing protocol. Category A: RCTs report comparative findings between clinical interventions for specified outcomes. Saline flush test: Can bedside sonography replace conventional radiography for confirmation of above-the-diaphragm central venous catheter placement? 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. Severe anaphylactic reaction due to a chlorhexidine-impregnated central venous catheter. Literature Findings. . 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. 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 . Eliminating arterial injury during central venous catheterization using manometry. 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 average age of the patients was 78.7 (45-100 years old . Although interobserver agreement among task force members and two methodologists was not assessed for this update, the original guidelines reported agreement levels using a statistic for two-rater agreement pairs as follows: (1) research design, = 0.70 to 1.00; (2) type of analysis, = 0.60 to 0.84; (3) evidence linkage assignment, = 0.91 to 1.00; and (4) literature inclusion for database, = 0.28 to 1.00. 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. Two episodes of life-threatening anaphylaxis in the same patient to a chlorhexidine-sulphadiazine-coated central venous catheter. The tube travels through one or more veins until the tip reaches the large vein that empties into your heart ( vena cava ). National Association of Childrens Hospitals and Related Institutions Pediatric Intensive Care Unit Central LineAssociated Bloodstream Infection Quality Transformation Teams. 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. The femoral vein is the major deep vein of the lower extremity. Always confirm placement with ultrasound, looking for reverberation artifact of the needle and tenting of the vessel wall. Comparison of Oligon catheters and chlorhexidine-impregnated sponges with standard multilumen central venous catheters for prevention of associated colonization and infections in intensive care unit patients: A multicenter, randomized, controlled study. The Texas Medical Center Catheter Study Group. Localize the vein by palpating the femoral artery, or use ultrasonography. Prevention of catheter-related bloodstream infection in critically ill patients using a disinfectable, needle-free connector: A randomized controlled trial. Femoral lines are usually used only as provisional access because they have a high risk of infection. . Verification of needle, wire, and catheter placement includes (1) confirming that the catheter or thin-wall needle resides in the vein, (2) confirming venous residence of the wire, and (3) confirming residence of the catheter in the venous system and final catheter tip position.. Confirmation of correct central venous catheter position in the preoperative setting by echocardiographic bubble-test.. The literature relating to seven evidence linkages contained enough studies with well defined experimental designs and statistical information to conduct formal meta-analyses (table 1). Survey Findings. Impact of a national multimodal intervention to prevent catheter-related bloodstream infection in the ICU: The Spanish experience. Guidewire catheter change in central venous catheter biofilm formation in a burn population. Trendelenburg position does not increase cross-sectional area of the internal jugular vein predictably. Transthoracic echocardiographic guidance for obtaining an optimal insertion length of internal jugular venous catheters in infants. Risk factors of failure and immediate complication of subclavian vein catheterization in critically ill patients. Evaluation and classification of evidence for the ASA clinical practice guidelines, Millers Anesthesia. An unexpected image on a chest radiograph. Catheter infection: A comparison of two catheter maintenance techniques. This line is placed in a large vein in the groin. Use of ultrasound to evaluate internal jugular vein anatomy and to facilitate central venous cannulation in paediatric patients. Anaphylaxis to chlorhexidine-coated central venous catheters: A case series and review of the literature. Statistically significant (P < 0.01) outcomes are designated as either beneficial (B) or harmful (H) for the patient; statistically nonsignificant findings are designated as equivocal (E). 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. Suture the line to allow 4 points of fixation. Iatrogenic injury of vertebral artery resulting in stroke after central venous line insertion. Submitted for publication March 15, 2019. Central venous catheters coated with minocycline and rifampin for the prevention of catheter-related colonization and bloodstream infections: A randomized, double-blind trial. Arterial misplacement of large-caliber cannulas during jugular vein catheterization: Case for surgical management. Comparison of triple-lumen central venous catheters impregnated with silver nanoparticles (AgTive). Level 3: The literature contains noncomparative observational studies with descriptive statistics (e.g., frequencies, percentages). A multicenter intervention to prevent catheter-associated bloodstream infections. A delayed diagnosis of a retained guidewire during central venous catheterisation: A case report and review of the literature. 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). Of the respondents, 82% indicated that the guidelines would have no effect on the amount of time spent on a typical case, and 17.6% indicated that there would be an increase of the amount of time spent on a typical case with the implementation of these guidelines. Each pertinent outcome reported in a study was classified by evidence category and level and designated as beneficial, harmful, or equivocal.