Prevention of central venous catheter-related infections by using maximal sterile barrier precautions during insertion. Use of electronic medical recordenhanced checklist and electronic dashboard to decrease CLABSIs. A multidisciplinary approach to reduce central lineassociated bloodstream infections. Guidewire localization by transthoracic echocardiography during central venous catheter insertion: A periprocedural method to evaluate catheter placement. Antiseptic-impregnated central venous catheters reduce the incidence of bacterial colonization and associated infection in immunocompromised transplant patients. Confirmation of endovenous placement of central catheter using the ultrasonographic bubble test., The use of ultrasound during and after central venous catheter insertion. Zero risk for central lineassociated bloodstream infection: Are we there yet? 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. Practice guidelines are systematically developed recommendations that assist the practitioner and patient in making decisions about health care. The procedure to place a femoral central line is as follows: You will have to lie down on your back for this procedure. 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. Iatrogenic arteriovenous fistula: A complication of percutaneous subclavian vein puncture. 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. Netcare Antimicrobial Stewardship and Infection Prevention Study Alliance. Literature Findings. The tube travels through one or more veins until the tip reaches the large vein that empties into your heart ( vena cava ). Complications of femoral and subclavian venous catheterization in critically ill patients: A randomized controlled trial. 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. Posterior cerebral infarction following loss of guide wire. Links to the digital files are provided in the HTML text of this article on the Journals Web site (www.anesthesiology.org). Effectiveness of stepwise interventions targeted to decrease central catheter-associated bloodstream infections. Ultrasound guidance outcomes were pooled using risk or mean differences (continuous outcomes) for clinical relevance. Reduction of catheter-related bloodstream infections through the use of a central venous line bundle: Epidemiologic and economic consequences. Level 3: The literature contains noncomparative observational studies with descriptive statistics (e.g., frequencies, percentages). Refer to appendix 3 for an example of a checklist or protocol. Survey Findings. 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. Level 2: The literature contains noncomparative observational studies with associative statistics (e.g., correlation, sensitivity, and specificity). 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. 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. (Committee Chair), Chicago, Illinois; Stephen M. Rupp, M.D. Prevention of catheter-related bloodstream infection in critically ill patients using a disinfectable, needle-free connector: A randomized controlled trial. Central venous catheter colonization and catheter-related bloodstream infections in critically ill patients: A comparison between standard and silver-integrated catheters. Impact of central venous catheter type and methods on catheter-related colonization and bacteraemia. Survey Findings. Evolution and aetiological shift of catheter-related bloodstream infection in a whole institution: The microbiology department may act as a watchtower. Central catheters provide dependable intravenous access and enable hemodynamic monitoring and blood sampling [ 1-3 ]. An Updated Report by the American Society of Anesthesiologists Task Force on Central Venous Access, A Tool to Screen Patients for Obstructive Sleep Apnea, ACE (Anesthesiology Continuing Education), Recommendations for Prevention of Infectious Complications, Recommendations for Prevention of Mechanical Trauma or Injury, Recommendations for Management of Arterial Trauma or Injury Arising from Central Venous Access, Appendix 3. Received from the American Society of Anesthesiologists, Schaumburg, Illinois. Category A: RCTs report comparative findings between clinical interventions for specified outcomes. R: A Language and Environment for Statistical Computing. Central venous access above the diaphragm, unless contraindicated, is generally preferred to femoral venous access in patients who require central venous access. Implementation of central venous catheter bundle in an intensive care unit in Kuwait: Effect on central lineassociated bloodstream infections. Comparison of silver-impregnated with standard multi-lumen central venous catheters in critically ill 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. Anaphylaxis to chlorhexidine in a chlorhexidine-coated central venous catheter during general anaesthesia. The ASA Committee on Standards and Practice Parameters reviews all practice guidelines at the ASA annual meeting and determines update and revision timelines. The syringe was removed and a guidewire was advanced through the needle into the femoral artery. 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. Confirmation of correct central venous catheter position in the preoperative setting by echocardiographic bubble-test.. Insert the J-curved end of the guidewire into the introducer needle, with the J curve facing up. (Co-Chair), Seattle, Washington; Avery Tung, M.D. Assessment of conceptual issues, practicality, and feasibility of the guideline recommendations was also evaluated, with opinion data collected from surveys and other sources. Nursing care. Catheter-Related Infections in ICU (CRI-ICU) Group. The consultants and ASA members strongly agree with the recommendation to use a chlorhexidine-containing solution for skin preparation in adults, infants, and children. Antimicrobial durability and rare ultrastructural colonization of indwelling central catheters coated with minocycline and rifampin. There are many uses of these catheters. A multicenter intervention to prevent catheter-associated bloodstream infections. Updated by the American Society of Anesthesiologists Task Force on Central Venous Access: Jeffrey L. Apfelbaum, M.D. The consultants and ASA members strongly agree with the recommendation to use aseptic techniques (e.g., hand washing) and maximal barrier precautions (e.g., sterile gowns, sterile gloves, caps, masks covering both mouth and nose, and full-body patient drapes) in preparation for the placement of central venous catheters. Palpating the femoral pulse throughout the procedure, the introducer needle was inserted into the femoral artery. 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. 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. ECG, electrocardiography; TEE, transesophageal echocardiography. 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). Supplemental Digital Content is available for this article. Allergy to chlorhexidine: Beware of the central venous catheter. 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. 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. Femoral vein cannulation performed by residents: A comparison between ultrasound-guided and landmark technique in infants and children undergoing cardiac surgery. The catheter over-the-needle technique may provide more stable venous access if manometry is used for venous confirmation. 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. Methods for confirming the position of the catheter tip include chest radiography, fluoroscopy, or point-of-care transthoracic echocardiography or continuous electrocardiography. Multimodal interventions for bundle implementation to decrease central lineassociated bloodstream infections in adult intensive care units in a teaching hospital in Taiwan, 20092013. Use of ultrasound to evaluate internal jugular vein anatomy and to facilitate central venous cannulation in paediatric patients. Incidence of mechanical complications of central venous catheterization using landmark technique: Do not try more than 3 times. 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. Level 4: The literature contains case reports. Impact of two bundles on central catheter-related bloodstream infection in critically ill patients. The consultants and ASA members strongly agree with the following recommendations: (1) determine the duration of catheterization based on clinical need; (2) assess the clinical need for keeping the catheter in place on a daily basis; (3) remove catheters promptly when no longer deemed clinically necessary; (4) inspect the catheter insertion site daily for signs of infection; (5) change or remove the catheter when catheter insertion site infection is suspected; and (6) when a catheter-related infection is suspected, replace the catheter using a new insertion site rather than changing the catheter over a guidewire. RCTs report equivocal findings for successful venipuncture when the internal jugular site is compared with the subclavian site (Category A2-E evidence).131,155,156 Equivocal finding are also reported for the femoral versus subclavian site (Category A2-E evidence),130,131 and the femoral versus internal jugular site (Category A3-E evidence).131 RCTs examining mechanical complications (primarily arterial injury, hematoma, and pneumothorax) report equivocal findings for the femoral versus subclavian site (Category A2-E evidence)130,131 as well as the internal jugular versus subclavian or femoral sites (Category A3-E evidence).131. The effect of hand hygiene compliance on hospital-acquired infections in an ICU setting in a Kuwaiti teaching hospital. Sustained reduction of central lineassociated bloodstream infections outside the intensive care unit with a multimodal intervention focusing on central line maintenance. 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. Comparison of the efficacy of three topical antiseptic solutions for the prevention of catheter colonization: A multicenter randomized controlled study. 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. Risk factors for catheter-related bloodstream infection: A prospective multicenter study in Brazilian intensive care units. 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. 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. Advance the wire 20 to 30 cm. The insertion process includes catheter site selection, insertion under ultrasound guidance, catheter site dressing regimens, securement devices, and use of a CVC insertion bundle. 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. Direct URL citations appear in the printed text and are available in both the HTML and PDF versions of this article. window the image to best visualize the line. Ultrasound identification of the guidewire in the brachiocephalic vein for the prevention of inadvertent arterial catheterization during internal jugular central venous catheter placement. Do not force the wire; it should slide smoothly. For neonates, infants, and children, confirmation of venous placement may take place after the wire is threaded. The Texas Medical Center Catheter Study Group. Real-time ultrasound-guided catheterisation of the internal jugular vein: A prospective comparison with the landmark technique in critical care patients. Survey findings from task forceappointed expert consultants and a random sample of the ASA membership are fully reported in the text of these guidelines. Order a chest x-ray to check for line position and pneumothorax if a jugular or subclavian line has . Comparison of central venous catheterization with and without ultrasound guide. 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. - 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. 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. Survey Findings. Comparison of triple-lumen central venous catheters impregnated with silver nanoparticles (AgTive). Trendelenburg position does not increase cross-sectional area of the internal jugular vein predictably. If you feel any resistance as you advance the guidewire, stop advancing it. Next, place the larger (20- to 22-gauge) needle immediately. Objective To investigate the efficacy of the minimally invasive clamp reduction technique via the anterior approach in the treatment of irreducible intertrochanteric femoral fractures. 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. Arterial trauma during central venous catheter insertion: Case series, review and proposed algorithm. A randomized trial comparing povidoneiodine to a chlorhexidine gluconate-impregnated dressing for prevention of central venous catheter infections in neonates. Preparation of these updated guidelines followed a rigorous methodological process. Sensitivity to effect measure was also examined. For meta-analyses of antimicrobial, silver, or silver-sulfadiazine catheters studies reported actual event rates and odds ratios were pooled. Catheter infection risk related to the distance between insertion site and burned area. Practice Guidelines for Central Venous Access 2020: An Updated Report by the American Society of Anesthesiologists Task Force on Central Venous Access. A minimum of five independent RCTs (i.e., sufficient for fitting a random-effects model255) is required for meta-analysis. If possible, this site is recommended by United States guidelines. 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. Statistically significant outcomes (P < 0.01) are designated as either beneficial (B) or harmful (H) for the patient; statistically nonsignificant findings are designated as equivocal (E). Confirmation of optimal guidewire length for central venous catheter placement using transesophageal echocardiography. Placing the central line. Findings from these RCTs are reported separately as evidence. Ultrasound evaluation of central veinsin the intensive care unit: Effects of dynamic manoeuvres. Literature Findings. These studies do not permit assessing the effect of any single component of a checklist or bundled protocol on infection rates. A prospective clinical trial to evaluate the microbial barrier of a needleless connector. Address correspondence to the American Society of Anesthesiologists: 1061 American Lane, Schaumburg, Illinois 60173. Effects of varying entry points and trendelenburg positioning degrees in internal jugular vein area measurements of newborns. Anesthesia was achieved using 1% lidocaine. Pacing catheters. This may be done in your hospital room or an . The accuracy of electrocardiogram-controlled central line placement. Needle insertion, wire placement, and catheter placement includes (1) selection of catheter size and type; (2) use of a wire-through-thin-wall needle technique (i.e., Seldinger technique) versus a catheter-over-the-needle-then-wire-through-the-catheter technique (i.e., modified Seldinger technique); (3) limiting the number of insertion attempts; and (4) introducing two catheters in the same central vein. An observational study reports that implementation of a trauma intensive care unit multidisciplinary checklist is associated with reduced catheter-related infection rates (Category B2-B evidence).6 Observational studies report that central lineassociated or catheter-related bloodstream infection rates are reduced when intensive care unit-wide bundled protocols are implemented736(Category B2-B evidence); evidence from fewer observational studies is equivocal3755(Category B2-E evidence); other observational studies5671 do not report levels of statistical significance or lacked sufficient data to calculate them. The central line is placed in your body during a brief procedure. Survey Findings. Ultrasound Guided Femoral Central Line Insertion Larry Mellick 612K subscribers Subscribe 405 Save 87K views 9 years ago Notice Age-restricted video (based on Community Guidelines) Comments are. I have read and accept the terms and conditions. Interventions intended to prevent mechanical trauma or injury associated with central venous access include but are not limited to (1) selection of catheter insertion site; (2) positioning the patient for needle insertion and catheter placement; (3) needle insertion, wire placement, and catheter placement; (4) guidance for needle, guidewire, and catheter placement, and (5) verification of needle, wire, and catheter placement. Reduced colonization and infection with miconazole-rifampicin modified central venous catheters: A randomized controlled clinical trial. 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. Survey Findings. 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. Central venous catheters are placed typically in one of 3 large central veins: the internal jugular vein (IJ), subclavian vein (SCL), or femoral vein. Case reports describe severe injury (e.g., hemorrhage, hematoma, pseudoaneurysm, arteriovenous fistula, arterial dissection, neurologic injury including stroke, and severe or lethal airway obstruction) when unintentional arterial cannulation occurs with large-bore catheters (Category B4-H evidence).169178, An RCT comparing a thin-wall needle technique versus a catheter-over-the-needle for right internal jugular vein insertion in adults reports equivocal findings for first-attempt success rates and frequency of complications (Category A3-E evidence)179; for right-sided subclavian insertion in adults an RCT reports first-attempt success more likely and fewer complications with a thin-wall needle technique (Category A3-B evidence).180 One RCT reports equivocal findings for first-attempt success rates and frequency of complications when comparing a thin-wall needle with catheter-over-the-needle technique for internal jugular vein insertion (preferentially right) in neonates (Category A3-E evidence).181 Observational studies report a greater frequency of complications occurring with increasing number of insertion attempts (Category B3-H evidence).182184 One nonrandomized comparative study reports a higher frequency of dysrhythmia when two central venous catheters are placed in the same vein (right internal jugular) compared with placement of one catheter in the vein (Category B1-H evidence); differences in carotid artery punctures or hematomas were not noted (Category B1-E evidence).185. New York State Regional Perinatal Care Centers. Reduced rates of catheter-associated infection by use of a new silver-impregnated central venous catheter. 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. After review, 729 were excluded, with 284 new studies meeting inclusion criteria. Microbiological evaluation of central venous catheter administration hubs. 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. Saline flush test: Can bedside sonography replace conventional radiography for confirmation of above-the-diaphragm central venous catheter placement? To view a bar chart with the above findings, refer to Supplemental Digital Content 5 (http://links.lww.com/ALN/C10). This description of the venous great vessels is consistent with the venous subset for central lines defined by the National Healthcare Safety Network. Prevention of central venous catheter sepsis: A prospective randomized trial. The femoral vein lies medial to the femoral artery as it runs distal to the inguinal ligament. These evidence categories are further divided into evidence levels.