Survey Findings. 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. Localize the vein by palpating the femoral artery, or use ultrasonography. Survey responses were recorded using a 5-point scale and summarized based on median values., Strongly agree: Median score of 5 (at least 50% of the responses are 5), Agree: Median score of 4 (at least 50% of the responses are 4 or 4 and 5), Equivocal: Median score of 3 (at least 50% of the responses are 3, or no other response category or combination of similar categories contain at least 50% of the responses), Disagree: Median score of 2 (at least 50% of responses are 2 or 1 and 2), Strongly disagree: Median score of 1 (at least 50% of responses are 1), The rate of return for the survey addressing guideline recommendations was 37% (n = 40 of 109) for consultants. The ASA Committee on Standards and Practice Parameters reviews all practice guidelines at the ASA annual meeting and determines update and revision timelines. 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. Methods for confirming that the catheter is still in the venous system after catheterization and before use include manometry or pressure-waveform measurement. Maintaining and sustaining the On the CUSP: Stop BSI model in Hawaii. An alternative central venous route for cardiac surgery: Supraclavicular subclavian vein catheterization. A chest x-ray will be performed immediately following thoracic central line placement to assure line placement and rule out pneumothorax. 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 development of evidence-based clinical practice guidelines: Integrating medical science and practice. Matching Michigan: A 2-year stepped interventional programme to minimise central venous catheter-blood stream infections in intensive care units in England. Allergy to chlorhexidine: Beware of the central venous catheter. 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. Meta-analyses from other sources are reviewed but not included as evidence in this document. Literature Findings. If a chlorhexidine-containing dressing is used, the consultants and ASA members both strongly agree with the recommendation to observe the site daily for signs of irritation, allergy or, necrosis. 1)****, Use real-time ultrasound guidance for vessel localization and venipuncture when the internal jugular vein is selected for cannulation (see fig. Monitoring central line pressure waveforms and pressures. 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. (Co-Chair), Seattle, Washington; Avery Tung, M.D. 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 literature is insufficient to evaluate the efficacy of transparent bioocclusive dressings to reduce the risk of infection. 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. Prevention of central venous catheter-related bloodstream infection by use of an antiseptic-impregnated catheter: A randomized, controlled trial. Decreasing catheter-related bloodstream infections in the intensive care unit: Interventions in a medical center in central Taiwan. It's made of a long, thin, flexible tube that enters your body through a vein. Aspirate and flush all lumens and re clamp and apply lumen caps. A 20-year retained guidewire: Should it be removed? In this document, only the highest level of evidence is included in the summary report for each interventionoutcome pair, including a directional designation of benefit, harm, or equivocality. Central venous line sepsis in the intensive care unit: A study comparing antibiotic coated catheters with plain catheters. Survey Findings. Central venous catheter colonization and catheter-related bloodstream infections in critically ill patients: A comparison between standard and silver-integrated catheters. Dressing Survey responses for each recommendation are reported using a 5-point scale based on median values from strongly agree to strongly disagree. Power analysis for random-effects meta-analysis. The consultants and ASA members strongly agree with the recommendation to use real-time ultrasound guidance for vessel localization and venipuncture when the internal jugular vein is selected for cannulation. Central line placement is a common . 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. The consultants and ASA members strongly agree with the recommendation to use a chlorhexidine-containing solution for skin preparation in adults, infants, and children. Ultrasound confirmation of guidewire position may eliminate accidental arterial dilatation during central venous cannulation. Impact of ultrasonography on central venous catheter insertion in intensive care. Implementation of central lineassociated bloodstream infection prevention bundles in a surgical intensive care unit using peer tutoring. They also may serve as a resource for other physicians (e.g., surgeons, radiologists), nurses, or healthcare providers who manage patients with central venous catheters. Remove the dilator and pass the central line over the Seldinger wire. A total of 3 supervised re-wires is required prior to performing a rewire . Three-rater values between two methodologists and task force reviewers were: (1) research design, = 0.70; (2) type of analysis, = 0.68; (3) linkage assignment, = 0.79; and (4) literature database inclusion, = 0.65. Complications and failures of subclavian-vein catheterization. Anesthesia was achieved using 1% lidocaine. The femoral vein lies medial to the femoral artery as it runs distal to the inguinal ligament. Hospital-wide multidisciplinary, multimodal intervention programme to reduce central venous catheter-associated bloodstream infection. Retention of antibacterial activity and bacterial colonization of antiseptic-bonded central venous catheters. Survey findings from task forceappointed expert consultants and a random sample of the ASA membership are fully reported in the text of these guidelines. Literature Findings. Comparison of silver-impregnated with standard multi-lumen central venous catheters in critically ill patients. 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. Links to the digital files are provided in the HTML text of this article on the Journals Web site (www.anesthesiology.org). Complications of femoral and subclavian venous catheterization in critically ill patients: A randomized controlled trial. The effect of process control on the incidence of central venous catheter-associated bloodstream infections and mortality in intensive care units in Mexico. Incidence of mechanical complications of central venous catheterization using landmark technique: Do not try more than 3 times. Local anesthetic is used to numb the insertion site. Improvement of internal jugular vein cannulation using an ultrasound-guided technique. Literature Findings. Insert the J-curved end of the guidewire into the introducer needle, with the J curve facing up. 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. 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. complications such as central venous stenosis, access thrombosis, or exhaustion of suitable access sites in the upper extremity, ultimately result in pursuing vascular access creation in the lower . Effectiveness of a programme to reduce the burden of catheter-related bloodstream infections in a tertiary hospital. Identical surveys were distributed to expert consultants and a random sample of members of the participating organizations. From ICU to hospital-wide: Extending central line associated bacteraemia (CLAB) prevention. Approved by the American Society of Anesthesiologists House of Delegates on October 23, 2019. Confirmation of endovenous placement of central catheter using the ultrasonographic bubble test., The use of ultrasound during and after central venous catheter insertion. Comparison of the efficacy of three topical antiseptic solutions for the prevention of catheter colonization: A multicenter randomized controlled study. Use real-time ultrasound guidance for vessel localization and venipuncture when the internal jugular vein is selected for cannulation (see fig. Fatal respiratory obstruction following insertion of a central venous line. The epidemiology, antibiograms and predictors of mortality among critically-ill patients with central lineassociated bloodstream infections. Category B: Observational studies or RCTs without pertinent comparison groups may permit inference of beneficial or harmful relationships among clinical interventions and clinical outcomes. This update is a revision developed by an ASA-appointed task force of seven members, including five anesthesiologists and two methodologists. The literature is insufficient to evaluate whether cleaning ports or capping stopcocks when using an existing central venous catheter for injection or aspiration decreases the risk of catheter-related infections. Do not force the wire; it should slide smoothly. 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. This line is placed in a large vein in the groin. Decreasing PICU catheter-associated bloodstream infections: NACHRIs quality transformation efforts. Femoral line. The syringe was removed and a guidewire was advanced through the needle into the femoral artery. 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. This line is placed into a large vein in the neck. Use full sterile dress. 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. Opinion surveys were developed by the task force to address each clinical intervention identified in the document. The consultants and ASA members both agree with the recommendation that dressings containing chlorhexidine may be used in adults, infants, and children unless contraindicated. Received from the American Society of Anesthesiologists, Schaumburg, Illinois. Central venous catheterization: A prospective, randomized, double-blind study. Example Duties Performed by an Assistant for Central Venous Catheterization. Preoperative chlorhexidine anaphylaxis in a patient scheduled for coronary artery bypass graft: A case report. Impregnated central venous catheters for prevention of bloodstream infection in children (the CATCH trial): A randomised controlled trial. Fluoroscopy-guided subclavian vein catheterization in 203 children with hematologic disease. Literature Findings. Trendelenburg position does not increase cross-sectional area of the internal jugular vein predictably. Alcoholic povidoneiodine to prevent central venous catheter colonization: A randomized unit-crossover study. 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 needle was exchanged over the wire for an arterial . 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. This may be done in your hospital room or an . Reducing central lineassociated bloodstream infections in three ICUs at a tertiary care hospital in the United Arab Emirates. 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. Findings from these RCTs are reported separately as evidence. Confirmation of internal jugular guide wire position utilizing transesophageal echocardiography. Central Line Insertion Care Team Checklist Instructions Operator Requirements: Specify minimum requirements. Influence of triple-lumen central venous catheters coated with chlorhexidine and silver sulfadiazine on the incidence of catheter-related bacteremia. Verification methods for needle, wire, or catheter placement may include any one or more of the following: ultrasound, manometry, pressure-waveform analysis, venous blood gas, fluoroscopy, continuous electrocardiography, transesophageal echocardiography, and chest radiography. Refer to appendix 5 for a summary of methods and analysis. Survey Findings. Advance the wire 20 to 30 cm. visualize the tip of the line. No difference in catheter sepsis between standard and antiseptic central venous catheters: A prospective randomized trial. Efficacy of silver-coating central venous catheters in reducing bacterial colonization. **, Comparative studies are insufficient to evaluate the efficacy of chlorhexidine and alcohol compared with chlorhexidine without alcohol for skin preparation during central venous catheterization. Fixed-effects models were fitted using MantelHaenszel or inverse variance weighting as appropriate. Sensitivity to effect measure was also examined. The consultants strongly agree and ASA members agree with the recommendation to not routinely administer intravenous antibiotic prophylaxis. 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. Eliminating catheter-related bloodstream infections in the intensive care unit. The consultants and ASA members strongly agree with the recommendation to perform central venous catheterization in an environment that permits use of aseptic techniques and to ensure that a standardized equipment set is available for central venous access. For neonates, the consultants and ASA members agree with the recommendation to determine the use of chlorhexidine-containing solutions for skin preparation based on clinical judgment and institutional protocol. 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. Ultrasonography: A novel approach to central venous cannulation. Methods for confirming the position of the catheter tip include chest radiography, fluoroscopy, or point-of-care transthoracic echocardiography or continuous electrocardiography. A prospective randomized study to compare ultrasound-guided with nonultrasound-guided double lumen internal jugular catheter insertion as a temporary hemodialysis access. . Prevention of catheter-related infections by silver coated central venous catheters in oncological patients. 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#. 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. 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). Cerebral infarct following central venous cannulation. An evaluation with ultrasound. 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). Decreasing central-lineassociated bloodstream infections in Connecticut intensive care units. The type of catheter and location of placement will depend on the reason for it's placement. 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. 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. Your physician will locate the femoral pulse with their nondominant hand. 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. In 2017, the ASA Committee on Standards and Practice Parameters requested that these guidelines be updated. Literature Findings. For example: o A minimum of 5 supervised successful procedures in both the chest and femoral sites is required (10 total). Prevention of mechanical trauma or injury: Patient preparation for needle insertion and catheter placement, Awake versus anesthetized patient during insertion, Positive pressure (i.e., mechanical) versus spontaneous ventilation during insertion, Patient position: Trendelenburg versus supine, Surface landmark inspection to identify target vein, Selection of catheter composition (e.g., polyvinyl chloride, polyethylene, Teflon), Selection of catheter type (all types will be compared with each other), Use of a finder (seeker) needle versus no seeker needle (e.g., a wider-gauge access needle), Use of a thin-wall needle versus a cannula over a needle before insertion of a wire for the Seldinger technique, Monitoring for needle, wire, and catheter placement, Ultrasound (including audio-guided Doppler ultrasound), Prepuncture identification of insertion site versus no ultrasound, Guidance during needle puncture and placement versus no ultrasound, Confirmation of venous insertion of needle, Identification of free aspiration of dark (Po2) nonpulsatile blood, Confirmation of venous placement of catheter, Manometry versus direct pressure measurement (via pressure transducer), Timing of x-ray immediately after placement versus postop. The searches covered an 8.3-yr period from January 1, 2011, through April 30, 2019. 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 A delayed diagnosis of a retained guidewire during central venous catheterisation: A case report and review of the literature. For meta-analyses of antimicrobial, silver, or silver-sulfadiazine catheters studies reported actual event rates and odds ratios were pooled. 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. Reduction of catheter-related infections in neutropenic patients: A prospective controlled randomized trial using a chlorhexidine and silver sulfadiazine-impregnated central venous catheter. Ultrasound identification of the guidewire in the brachiocephalic vein for the prevention of inadvertent arterial catheterization during internal jugular central venous catheter placement. Practice guidelines for central venous access: A report by the American Society of Anesthesiologists Task Force on Central Venous Access. Four hundred eighty-one (99.4%) placements were technically successful. (Committee Chair), Chicago, Illinois; Stephen M. Rupp, M.D. Comparison of central venous catheterization with and without ultrasound guide. Catheter-Related Infections in ICU (CRI-ICU) Group. RCTs comparing needleless connectors with standard caps indicate lower rates of microbial contamination of stopcock entry ports with needleless connectors (Category A2-B evidence),151153 but findings for catheter-related bloodstream infection are equivocal (Category A2-E evidence).151,154, Survey Findings. Is a routine chest x-ray necessary for children after fluoroscopically assisted central venous access? Prepare the centralcatheter kit, and Palpating the femoral pulse throughout the procedure, the introducer needle was inserted into the femoral artery. Impact of a national multimodal intervention to prevent catheter-related bloodstream infection in the ICU: The Spanish experience. Use of ultrasound to evaluate internal jugular vein anatomy and to facilitate central venous cannulation in paediatric patients. Images in cardiovascular medicine: Percutaneous retrieval of a lost guidewire that caused cardiac tamponade. An additional survey was sent to the consultants accompanied by a draft of the guidelines asking them to indicate which, if any, of the recommendations would change their clinical practices if the guidelines were instituted. Location of the central venous catheter tip with bedside ultrasound in young children: Can we eliminate the need for chest radiography? 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. 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). For neonates, infants, and children, confirmation of venous placement may take place after the wire is threaded. Of the 484 attempted placements, 472 (97.5%) were primary placements. A controlled study of transesophageal echocardiography to guide central venous catheter placement in congenital heart surgery patients. The SiteRite ultrasound machine: An aid to internal jugular vein cannulation. Managing inadvertent arterial catheterization during central venous access procedures. The femoral vein is the major deep vein of the lower extremity. There were three (0.6%) technical failures due to previously undiagnosed iliofemoral venous occlusive disease. Risk factors for central venous catheter-related infections in surgical and intensive care units. Evolution and aetiological shift of catheter-related bloodstream infection in a whole institution: The microbiology department may act as a watchtower. Femoral lines are usually used only as provisional access because they have a high risk of infection. ), Tunneled catheters (e.g., Hickman, Quinton, permacaths, portacaths), Arterial cannulation/injury/cerebral embolization/hemorrhage, Wire, knot, inability to remove the catheter, Hospital, intensive care unit length of stay, Number of attempts at central line placement, Time required for placement of central venous catheters, Infections or other complications not associated with central venous catheterization, Mechanical injury or trauma not associated with central venous catheterization, Prospective nonrandomized comparative studies (e.g., quasiexperimental, cohort), Retrospective comparative studies (e.g., case-control), Observational studies (e.g., correlational or descriptive statistics).