Order a chest x-ray to check for line position and pneumothorax if a jugular or subclavian line has . Chlorhexidine-impregnated dressings and prevention of catheter-associated bloodstream infections in a pediatric intensive care unit. The bubble study: Ultrasound confirmation of central venous catheter placement. Risk factors for central venous catheter-related infections in surgical and intensive care units. 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. Evidence levels refer specifically to the strength and quality of the summarized study findings (i.e., statistical findings, type of data, and the number of studies reporting/replicating the findings). Advance the wire 20 to 30 cm. Matching Michigan Collaboration & Writing Committee. Comparison of an ultrasound-guided technique. The variation between the two techniques reflects mitigation steps for the risk that the thin-wall needle in the Seldinger technique could move out of the vein and into the wall of an artery between the manometry step and the threading of the wire step. Prevention of central venous catheter related infections with chlorhexidine gluconate impregnated wound dressings: A randomized controlled trial. A minimum of 5 supervised successful procedures in both the chest and femoral sites is required (10 total). If a physician successfully performs the 5 supervised lines in one site, they are independent for that site only. Impact of a national multimodal intervention to prevent catheter-related bloodstream infection in the ICU: The Spanish experience. The consultants and ASA members strongly agree that for neonates, infants, and children, determine on a case-by-case basis whether to leave the catheter in place and obtain consultation or to remove the catheter nonsurgically. Improvement of internal jugular vein cannulation using an ultrasound-guided technique. **, Comparative studies are insufficient to evaluate the efficacy of chlorhexidine and alcohol compared with chlorhexidine without alcohol for skin preparation during central venous catheterization. Decreasing catheter-related bloodstream infections in the intensive care unit: Interventions in a medical center in central Taiwan. If a physician successfully performs the 5 supervised lines in one site, they are independent for that site only. There are a variety of catheter, both size and configuration. Ultrasonography: A novel approach to central venous cannulation. 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). Reduced colonization and infection with miconazole-rifampicin modified central venous catheters: A randomized controlled clinical trial. 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. A summary of recommendations can be found in appendix 1. All meta-analyses are conducted by the ASA methodology group. (Chair). Incidence of mechanical complications of central venous catheterization using landmark technique: Do not try more than 3 times. RCTs comparing continuous electrocardiographic guidance for catheter placement with no electrocardiography indicate that continuous electrocardiography is more effective in identifying proper catheter tip placement (Category A2-B evidence).245247 Case reports document unrecognized retained guidewires resulting in complications including embolization and fragmentation,248 infection,249 arrhythmia,250 cardiac perforation,248 stroke,251 and migration through soft-tissue (Category B-4H evidence).252. This document updates the Practice Guidelines for Central Venous Access: A Report by the American Society of Anesthesiologists Task Force on Central Venous Access, adopted by the ASA in 2011 and published in 2012.1. Address correspondence to the American Society of Anesthesiologists: 1061 American Lane, Schaumburg, Illinois 60173. Real-time ultrasound-guided catheterisation of the internal jugular vein: A prospective comparison with the landmark technique in critical care patients. Central catheters provide dependable intravenous access and enable hemodynamic monitoring and blood sampling [ 1-3 ]. A multicenter intervention to prevent catheter-associated bloodstream infections. Power analysis for random-effects meta-analysis. Chlorhexidine and silver-sulfadiazine coated central venous catheters in haematological patients: A double-blind, randomised, prospective, controlled trial. Assessment of a central lineassociated bloodstream infection prevention program in a burn-trauma intensive care unit. No search for gray literature was conducted. A controlled study of transesophageal echocardiography to guide central venous catheter placement in congenital heart surgery patients. The consultants and ASA members agree that when feasible, real-time ultrasound may be used when the subclavian or femoral vein is selected. 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. Five (1.0%) adverse events occurred. Placing the central line. Literature Findings. An evaluation with ultrasound. Inadequate literature cannot be used to assess relationships among clinical interventions and outcomes because a clear interpretation of findings is not obtained due to methodological concerns (e.g., confounding of study design or implementation) or the study does not meet the criteria for content as defined in the Focus of the guidelines. A subclavian artery injury, secondary to internal jugular vein cannulation, is a predictable right-sided phenomenon. 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. Ultrasound-guided internal jugular venous cannulation in infants: A prospective comparison with the traditional palpation method. Practice guidelines are subject to revision as warranted by the evolution of medical knowledge, technology, and practice. Skin antisepsis with chlorhexidinealcohol, for Japanese Society of Education for Physicians and Trainees in Intensive Care (JSEPTIC) Clinical Trial Group. 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. Preparation of these updated guidelines followed a rigorous methodological process. Advance the guidewire through the needle and into the vein. A randomized trial on chlorhexidine dressings for the prevention of catheter-related bloodstream infections in neutropenic patients. Comparison of triple-lumen central venous catheters impregnated with silver nanoparticles (AgTive). Heterogeneity was quantified with I2 and prediction intervals estimated (see table 1). Reduced rates of catheter-associated infection by use of a new silver-impregnated central venous catheter. visualize the tip of the line. Insert the introducer needle with negative pressure until venous blood is aspirated. Antimicrobial durability and rare ultrastructural colonization of indwelling central catheters coated with minocycline and rifampin. This algorithm compares the thin-wall needle (i.e., Seldinger) technique versus the catheter-over-the needle (i.e., modified Seldinger) technique in critical safety steps to prevent unintentional arterial placement of a dilator or large-bore catheter. Accepted for publication May 16, 2019. There were three (0.6%) technical failures due to previously undiagnosed iliofemoral venous occlusive disease. Pacing catheters. Insufficient Literature. There are many uses of these catheters. 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. Literature Findings. . 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). Practice Guidelines for Central Venous Access 2020: An Updated Report by the American Society of Anesthesiologists Task Force on Central Venous Access. Catheter-Related Infections in ICU (CRI-ICU) Group. 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 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. Retention of the antibiotic teicoplanin on a hydromer-coated central venous catheter to prevent bacterial colonization in postoperative surgical patients. 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. Reduction of central line infections in Veterans Administration intensive care units: An observational cohort using a central infrastructure to support learning and improvement. Category A: RCTs report comparative findings between clinical interventions for specified outcomes. The consultants and ASA members both strongly agree with the recommendations to use transparent bioocclusive dressings to protect the site of central venous catheter insertion from infection. Survey Findings. subclavian vein (left or right) assessing position. 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. In total, 4,491 unique new citations were identified, with 1,013 full articles assessed for eligibility. Both the systematic literature review and the opinion data are based on evidence linkages or statements regarding potential relationships between interventions and outcomes associated with central venous access. Insert the J-curved end of the guidewire into the introducer needle, with the J curve facing up. The syringe was removed and a guidewire was advanced through the needle into the femoral artery. Effectiveness of a programme to reduce the burden of catheter-related bloodstream infections in a tertiary hospital. Anaphylaxis to chlorhexidine in a chlorhexidine-coated central venous catheter during general anaesthesia. In 2017, the ASA Committee on Standards and Practice Parameters requested that these guidelines be updated. 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. 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. Level 4: The literature contains case reports. Efficacy of antiseptic-impregnated catheters on catheter colonization and catheter-related bloodstream infections in patients in an intensive care unit. 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. Decreasing catheter colonization through the use of an antiseptic-impregnated catheter: A continuous quality improvement project. Eliminating arterial injury during central venous catheterization using manometry. The original guidelines were developed by an ASA appointed task force of 12 members, consisting of anesthesiologists in private and academic practices from various geographic areas of the United States and two methodologists from the ASA Committee on Standards and Practice Parameters. This line is placed in a large vein in the groin. A 20-year retained guidewire: Should it be removed? Comparison of the effect of the Trendelenburg and passive leg raising positions on internal jugular vein size in critically ill patients. Anaphylactic shock induced by an antiseptic-coated central venous [correction of nervous] catheter. Management of trauma or injury arising from central venous catheterization: Management of arterial cannulation, arterial injury, or cerebral embolization, Pulling out a catheter from the carotid artery versus the subclavian artery, Immediate removal versus retaining catheter until a vascular surgery consult is obtained, Management of catheter or wire shearing or loss, Management of hemo/pneumothorax; retroperitoneal bleeding after femoral catheterization, Management of wire knot, wire, or catheter that will not come out, Management of thromboembolism during removal, Floatation and residence (i.e., maintenance) issues of a pulmonary artery catheter, Central venous catheters versus other methods of assessing volume status or presence of tamponade/pericarditis (e.g., pulse pressure variability and echo), Clinical indications for placement of central venous catheters, Detection and treatment of infectious complications, Education, training, and certification of providers, Monitoring central line pressure waveforms and pressures, 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, etc. 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. The tube travels through one or more veins until the tip reaches the large vein that empties into your heart ( vena cava ). The literature is insufficient to evaluate the efficacy of transparent bioocclusive dressings to reduce the risk of infection. Random-effects models were fitted with inverse variance weighting using the DerSimonian and Laird estimate of between-study variance. Treatment of irreducible intertrochanteric femoral fracture with a 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. 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 accuracy of electrocardiogram-controlled central line placement. 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. A multitiered strategy of simulation training, kit consolidation, and electronic documentation is associated with a reduction in central lineassociated bloodstream infections. The long-term effect of bundle care for catheter-related blood stream infection: 5-year follow-up. The consultants strongly agree and ASA members agree with the recommendation to not routinely administer intravenous antibiotic prophylaxis. The consultants and ASA members strongly agree with the recommendations to wipe catheter access ports with an appropriate antiseptic (e.g., alcohol) before each access when using an existing central venous catheter for injection or aspiration and to cap central venous catheter stopcocks or access ports when not in use. Ultrasound identification of the guidewire in the brachiocephalic vein for the prevention of inadvertent arterial catheterization during internal jugular central venous catheter placement. This approach may not be feasible in emergency circumstances or in the presence of other clinical constraints. 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. Confirmation of correct central venous catheter position in the preoperative setting by echocardiographic bubble-test.. Matching Michigan: A 2-year stepped interventional programme to minimise central venous catheter-blood stream infections in intensive care units in England. The searches covered an 8.3-yr period from January 1, 2011, through April 30, 2019. Reducing central lineassociated bloodstream infections in three ICUs at a tertiary care hospital in the United Arab Emirates. The consultants and ASA members both strongly agree with the recommendation to minimize the number of needle punctures of the skin. Images in cardiovascular medicine: Percutaneous retrieval of a lost guidewire that caused cardiac tamponade. Meta-analyses of RCTs comparing antibiotic-coated with uncoated catheters indicates that antibiotic-coated catheters are associated with reduced catheter colonization7885 and catheter-related bloodstream infection (Category A1-B evidence).80,81,83,85,86 Meta-analyses of RCTs comparing silver or silver-platinum-carbonimpregnated catheters with uncoated catheters yield equivocal findings for catheter colonization (Category A1-E evidence)8797 but a decreased risk of catheter-related bloodstream infection (Category A1-B evidence).8794,9699 Meta-analyses of RCTs indicate that catheters coated with chlorhexidine and silver sulfadiazine reduce catheter colonization compared with uncoated catheters (Category A1-B evidence)83,95,100118 but are equivocal for catheter-related bloodstream infection (Category A1-E evidence).83,100102,104110,112117,119,120 Cases of anaphylactic shock are reported after placement of a catheter coated with chlorhexidine and silver sulfadiazine (Category B4-H evidence).121129. 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. The needle was exchanged over the wire for an arterial . Reduction and surveillance of device-associated infections in adult intensive care units at a Saudi Arabian hospital, 20042011. A sonographically guided technique for central venous access. Inferred findings are given a directional designation of beneficial (B), harmful (H), or equivocal (E). These guidelines apply to patients undergoing elective central venous access procedures performed by anesthesiologists or healthcare professionals under the direction/supervision of anesthesiologists. Prevention of central venous catheter sepsis: A prospective randomized trial. . 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. Use of ultrasound to evaluate internal jugular vein anatomy and to facilitate central venous cannulation in paediatric patients. 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. An intervention to decrease catheter-related bloodstream infections in the ICU.