A prospective randomized trial of an antibiotic- and antiseptic-coated central venous catheter in the prevention of catheter-related infections. Implementation of central venous catheter bundle in an intensive care unit in Kuwait: Effect on central lineassociated bloodstream infections. Using the comprehensive unit-based safety program model for sustained reduction in hospital infections. 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 localization of central vein catheter and detection of postprocedural pneumothorax: An alternative to chest radiography. Preparation of these updated guidelines followed a rigorous methodological process. 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. Chlorhexidine and silver-sulfadiazine coated central venous catheters in haematological patients: A double-blind, randomised, prospective, controlled trial. These recommendations may be adopted, modified, or rejected according to clinical needs and constraints and are not intended to replace local institutional policies. Randomized controlled trial of chlorhexidine dressing and highly adhesive dressing for preventing catheter-related infections in critically ill adults. Comparison of triple-lumen central venous catheters impregnated with silver nanoparticles (AgTive). Survey Findings. Only studies containing original findings from peer-reviewed journals were acceptable. Fluoroscopy-guided subclavian vein catheterization in 203 children with hematologic disease. Prospective comparison of ultrasound and CXR for confirmation of central vascular catheter placement. For example: o A minimum of 5 supervised successful procedures in both the chest and femoral sites is required (10 total). Misplacement of a guidewire diagnosed by transesophageal echocardiography. Arterial misplacement of large-caliber cannulas during jugular vein catheterization: Case for surgical management. 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. Matching Michigan Collaboration & Writing Committee. Internal jugular line. ECG, electrocardiography; TEE, transesophageal echocardiography. Decreasing PICU catheter-associated bloodstream infections: NACHRIs quality transformation efforts. Anaphylactic shock induced by an antiseptic-coated central venous [correction of nervous] catheter. Cerebral infarct following central venous cannulation. New York State Regional Perinatal Care Centers. A significance level of P < 0.01 was applied for analyses. 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. All meta-analyses are conducted by the ASA methodology group. 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. Survey Findings. Approved by the American Society of Anesthesiologists House of Delegates on October 23, 2019. 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. Prevention of catheter-related infections by silver coated central venous catheters in oncological patients. Literature Findings. Prevention of intravascular catheter-related infection with newer chlorhexidine-silver sulfadiazinecoated catheters: A randomized controlled trial. Anesthesia was achieved using 1% lidocaine. A prospective randomized study. Practice guidelines are subject to revision as warranted by the evolution of medical knowledge, technology, and practice. tip too high: proximal SVC. Insert the introducer needle with negative pressure until venous blood is aspirated. 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. Sensitivity to effect measure was also examined. Because not all studies of dressings reported event rates, relative risks or hazard ratios (recognizing they approximate relative risks) were pooled. Evidence was obtained from two principal sources: scientific evidence and opinion-based evidence. Does ultrasound imaging before puncture facilitate internal jugular vein cannulation? This line is placed into the vein that runs behind the collarbone. The long-term impact of a program to prevent central lineassociated bloodstream infections in a surgical intensive care unit. Venous blood gases must be obtained at the time of central line insertion or upon admission of a patient with an established central line (including femoral venous lines) and as an endpoint to resuscitation or . A prospective clinical trial to evaluate the microbial barrier of a needleless connector. Literature Findings. Survey Findings. Category A evidence represents results obtained from RCTs, and category B evidence represents observational results obtained from nonrandomized study designs or RCTs without pertinent comparison groups. Survey Findings. Eradicating central lineassociated bloodstream infections statewide: The Hawaii experience. Anaphylaxis to chlorhexidine in a chlorhexidine-coated central venous catheter during general anaesthesia. Retention of antibacterial activity and bacterial colonization of antiseptic-bonded central venous catheters. Ultrasound as a screening tool for central venous catheter positioning and exclusion of pneumothorax. The consultants and ASA members agree that when feasible, real-time ultrasound may be used when the subclavian or femoral vein is selected. Publications identified by task force members were also considered. This line is placed in a large vein in the groin. Alcoholic povidoneiodine to prevent central venous catheter colonization: A randomized unit-crossover study. The development of evidence-based clinical practice guidelines: Integrating medical science and practice. Ultrasound identification of the guidewire in the brachiocephalic vein for the prevention of inadvertent arterial catheterization during internal jugular central venous catheter placement. window the image to best visualize the line. Chlorhexidine-related refractory anaphylactic shock: A case successfully resuscitated with extracorporeal membrane oxygenation. In total, 4,491 unique new citations were identified, with 1,013 full articles assessed for eligibility. These large diameter central veins are located universally near a large artery. 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. All opinion-based evidence relevant to each topic was considered in the development of these guidelines. A minimum of five independent RCTs (i.e., sufficient for fitting a random-effects model255) is required for meta-analysis. Chlorhexidine and gauze and tape dressings for central venous catheters: A randomized clinical trial. ( 21460264) Transition to a PICC line for long-term central access. Real-time ultrasound-guided catheterisation of the internal jugular vein: A prospective comparison with the landmark technique in critical care patients. ), 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). Literature Findings. Femoral vein cannulation performed by residents: A comparison between ultrasound-guided and landmark technique in infants and children undergoing cardiac surgery. No respondents indicated that new equipment, supplies, or training would not be needed to implement the guidelines, and 88.9% indicated that implementation of the guidelines would not require changes in practice that would affect costs. Risk factors for catheter-related bloodstream infection: A prospective multicenter study in Brazilian intensive care units. Fatal brainstem stroke following internal jugular vein catheterization. An unexpected image on a chest radiograph. 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. Direct URL citations appear in the printed text and are available in both the HTML and PDF versions of this article. This is acceptable so long as you inform the accepting service that the line is not full sterile. The consultants and ASA members strongly agree with the recommendation to use a chlorhexidine-containing solution for skin preparation in adults, infants, and children. Confirmation of correct central venous catheter position in the preoperative setting by echocardiographic bubble-test.. Accurate placement of central venous catheters: A prospective, randomized, multicenter trial. Impact of a national multimodal intervention to prevent catheter-related bloodstream infection in the ICU: The Spanish experience. Central line placement is a common . Guidewire localization by transthoracic echocardiography during central venous catheter insertion: A periprocedural method to evaluate catheter placement. 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. Survey Findings. Level 4: The literature contains case reports. Insert the J-curved end of the guidewire into the introducer needle, with the J curve facing up. Catheter-associated bloodstream infection in the pediatric intensive care unit: A multidisciplinary approach. I have read and accept the terms and conditions. Editorials, letters, and other articles without data were excluded. Randomized, controlled clinical trial of point-of-care limited ultrasonography assistance of central venous cannulation: The Third Sonography Outcomes Assessment Program (SOAP-3) Trial. Suture the line to allow 4 points of fixation. 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. This description of the venous great vessels is consistent with the venous subset for central lines defined by the National Healthcare Safety Network. For these guidelines, central venous access is defined as placement of a catheter such that the catheter is inserted into a venous great vessel. Your physician will locate the femoral pulse with their nondominant hand. A prospective randomized study to compare ultrasound-guided with nonultrasound-guided double lumen internal jugular catheter insertion as a temporary hemodialysis access. Survey Findings. Example Duties Performed by an Assistant for Central Venous Catheterization. A controlled study of transesophageal echocardiography to guide central venous catheter placement in congenital heart surgery patients. Netcare Antimicrobial Stewardship and Infection Prevention Study Alliance. Ultrasound guidance outcomes were pooled using risk or mean differences (continuous outcomes) for clinical relevance. (Co-Chair), Wilmette, Illinois; Richard T. Connis, Ph.D. (Chief Methodologist), Woodinville, Washington; Karen B. Domino, M.D., M.P.H., Seattle, Washington; Mark D. Grant, M.D., Ph.D. (Senior Methodologist), Schaumburg, Illinois; and Jonathan B. 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). Biopatch: A new concept in antimicrobial dressings for invasive devices. Implementing a multifaceted intervention to decrease central lineassociated bloodstream infections in SEHA (Abu Dhabi Health Services Company) intensive care units: The Abu Dhabi experience. Reduction of central lineassociated bloodstream infection rates in patients in the adult intensive care unit. Interventions intended to prevent infectious complications associated with central venous access include, but are not limited to, (1) intravenous antibiotic prophylaxis; (2) aseptic preparation of practitioner, staff, and patients; (3) selection of antiseptic solution; (4) selection of catheters containing antimicrobial agents; (5) selection of catheter insertion site; (6) catheter fixation method; (7) insertion site dressings; (8) catheter maintenance procedures; and (9) aseptic techniques using an existing central venous catheter for injection or aspiration. Reduction of central line infections in Veterans Administration intensive care units: An observational cohort using a central infrastructure to support learning and improvement. For meta-analyses of antimicrobial, silver, or silver-sulfadiazine catheters studies reported actual event rates and odds ratios were pooled. Incidence of mechanical complications of central venous catheterization using landmark technique: Do not try more than 3 times. A 20-year retained guidewire: Should it be removed? The consultants strongly agree and ASA members agree with the recommendation that after the injury has been evaluated and a treatment plan has been executed, confer with the surgeon regarding relative risks and benefits of proceeding with the elective surgery versus deferring surgery to allow for a period of patient observation. Positioning the tip of a central venous catheter (CVC) within the superior vena cava (SVC) at or just above the level of the carina is generally considered acceptable for most short-term uses, such as fluid administration or monitoring of central venous pressure. The percentage of responding consultants expecting no change associated with each linkage were as follows: (1) resource preparation (environment with aseptic techniques, standardized equipment set) = 89.5%; (2) use of a trained assistant = 100%; (3) use of a checklist or protocol for placement and maintenance = 89.5%; (4) aseptic preparation (hand washing, sterile full-body drapes, etc.) Comparison of the effect of the Trendelenburg and passive leg raising positions on internal jugular vein size in critically ill patients. Advance the wire 20 to 30 cm. Risk factors for central venous catheter-related infections in surgical and intensive care units. The consultants strongly agree and ASA members agree with the recommendation to not routinely administer intravenous antibiotic prophylaxis. Reduction of catheter-related infections in neutropenic patients: A prospective controlled randomized trial using a chlorhexidine and silver sulfadiazine-impregnated central venous catheter. Efficacy of silver-coating central venous catheters in reducing bacterial colonization. Level 3: The literature contains a single RCT, and findings from this study are reported as evidence. For these updated guidelines, a systematic search and review of peer-reviewed published literature was conducted, with scientific findings summarized and reported below and in the document. These evidence categories are further divided into evidence levels. Pooled estimates from RCTs are consistent with lower rates of catheter colonization with chlorhexidine sponge dressings compared with standard polyurethane (Category A1-B evidence)90,133138 but equivocal for catheter-related bloodstream infection (Category A1-E evidence).90,133140 An RCT reports a higher frequency of severe localized contact dermatitis in neonates with chlorhexidine-impregnated dressings compared with povidoneiodineimpregnated dressings (Category A3-H evidence)133; findings concerning dermatitis from RCTs in adults are equivocal (Category A2-E evidence).90,134,136,137,141. 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. 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). This may be done in your hospital room or an . (Committee Chair), Chicago, Illinois; Stephen M. Rupp, M.D. Guidance for needle, wire, and catheter placement includes (1) real-time or dynamic ultrasound for vessel localization and guiding the needle to its intended venous location and (2) static ultrasound imaging for the purpose of prepuncture vessel localization. Remove the dilator and pass the central line over the Seldinger wire. Failure of antiseptic bonding to prevent central venous catheter-related infection and sepsis. The consultants and ASA members agree that static ultrasound may also be used when the subclavian or femoral vein is selected. To view a bar chart with the above findings, refer to Supplemental Digital Content 5 (http://links.lww.com/ALN/C10). 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. Metasens: Advanced Statistical Methods to Model and Adjust for Bias in Meta-Analysis. 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.
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