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. 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. 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. Comparison of silver-impregnated with standard multi-lumen central venous catheters in critically ill patients. Eradicating central lineassociated bloodstream infections statewide: The Hawaii experience. Advance the wire 20 to 30 cm. Central venous catheter colonization in critically ill patients: A prospective, randomized, controlled study comparing standard with two antiseptic-impregnated catheters. In most instances, central venous access with ultrasound guidance is considered the standard of care. Prevention of central venous catheter-related infections by using maximal sterile barrier precautions during insertion. : Prospective randomized comparison with landmark-guided puncture in ventilated patients. Prevention of catheter related bloodstream infection by silver iontophoretic central venous catheters: A randomised controlled trial. Anesthesia was achieved using 1% lidocaine. All opinion-based evidence relevant to each topic was considered in the development of these guidelines. Multidisciplinary trauma intensive care unit checklist: Impact on infection rates. Please read and accept the terms and conditions and check the box to generate a sharing link. Randomized controlled trial of chlorhexidine dressing and highly adhesive dressing for preventing catheter-related infections in critically ill adults. Central venous catheterization: A prospective, randomized, double-blind study. Survey Findings. When available, category A evidence is given precedence over category B evidence for any particular outcome. Comparison of bacterial colonization rates of antiseptic impregnated and pure polymer central venous catheters in the critically ill. A comparison between two types of central venous catheters in the prevention of catheter-related infections: The importance of performing all the relevant cultures. Reduction and surveillance of device-associated infections in adult intensive care units at a Saudi Arabian hospital, 20042011. If a physician successfully performs the 5 supervised lines in one site, they are independent for that site only. The SiteRite ultrasound machine: An aid to internal jugular vein cannulation. 1), The number of insertion attempts should be based on clinical judgment, The decision to place two catheters in a single vein should be made on a case-by-case basis. Eliminating catheter-related bloodstream infections in the intensive care unit. 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. Bibliographic database searches included PubMed and EMBASE. Survey Findings. 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. 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. This line is placed in a large vein in the groin. Real-time ultrasound-guided subclavian vein cannulation, The influence of the direction of J-tip on the placement of a subclavian catheter: Real time ultrasound-guided cannulation. Methods for confirming the position of the catheter tip include chest radiography, fluoroscopy, or point-of-care transthoracic echocardiography or continuous electrocardiography. The consultants and ASA members agree that static ultrasound may also be used when the subclavian or femoral vein is selected. Central venous line sepsis in the intensive care unit: A study comparing antibiotic coated catheters with plain catheters. Implementing a multifaceted intervention to decrease central lineassociated bloodstream infections in SEHA (Abu Dhabi Health Services Company) intensive care units: The Abu Dhabi experience. A summary of recommendations can be found in appendix 1. Ultrasound identification of the guidewire in the brachiocephalic vein for the prevention of inadvertent arterial catheterization during internal jugular central venous catheter placement. visualize the tip of the line. 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. The consultants and ASA members strongly agree with the recommendation to use a chlorhexidine-containing solution for skin preparation in adults, infants, and children. A significance level of P < 0.01 was applied for analyses. A prospective randomized study to compare ultrasound-guided with nonultrasound-guided double lumen internal jugular catheter insertion as a temporary hemodialysis access. Refer to appendix 3 for an example of a checklist or protocol. Ultrasound confirmation of guidewire position may eliminate accidental arterial dilatation during central venous cannulation. Power analysis for random-effects meta-analysis. This line is placed into a large vein in the neck. 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). Choice of route for central venous cannulation: Subclavian or internal jugular vein? The results of the surveys are reported in tables 2 and 3 and are summarized in the text of the guidelines.#####, American Society of Anesthesiologists Member Survey Results. American Society of Anesthesiologists Task Force on Central Venous A. Mark, M.D., Durham, North Carolina. Reduction of catheter-related infections in neutropenic patients: A prospective controlled randomized trial using a chlorhexidine and silver sulfadiazine-impregnated central venous catheter. Evidence categories refer specifically to the strength and quality of the research design of the studies. A prospective clinical trial to evaluate the microbial barrier of a needleless connector. Survey Findings. NICE guidelines for central venous catheterization in children: Is the evidence base sufficient? Central vascular catheter placement evaluation using saline flush and bedside echocardiography. Literature Findings. Opinion surveys were developed by the task force to address each clinical intervention identified in the document. Survey Findings. Verification of needle, wire, and catheter placement includes (1) confirming that the catheter or thin-wall needle resides in the vein, (2) confirming venous residence of the wire, and (3) confirming residence of the catheter in the venous system and final catheter tip position.. A subclavian artery injury, secondary to internal jugular vein cannulation, is a predictable right-sided phenomenon. The femoral vein is the major deep vein of the lower extremity. The consultants and ASA members both agree with the recommendation that dressings containing chlorhexidine may be used in adults, infants, and children unless contraindicated. ), 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). Allergy to chlorhexidine: Beware of the central venous catheter. Sensitivity to effect measure was also examined. Beyond the intensive care unit bundle: Implementation of a successful hospital-wide initiative to reduce central lineassociated bloodstream infections. Peripheral IV insertion and care. The subclavian veins are an often favored site for central venous access, including emergency and acute care access, and tunneled catheters and subcutaneous ports for chemotherapy, prolonged antimicrobial therapy, and parenteral . Citation searching (backward and forward) of relevant meta-analyses and other systematic reviews was also performed; pre-2011 studies relevant to meta-analyses or use of ultrasound were eligible for inclusion. Level 3: The literature contains noncomparative observational studies with descriptive statistics (e.g., frequencies, percentages). Practice guidelines are subject to revision as warranted by the evolution of medical knowledge, technology, and practice. Survey Findings. The incidence of complications after the double-catheter technique for cannulation of the right internal jugular vein in a university teaching hospital. 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. The long-term impact of a program to prevent central lineassociated bloodstream infections in a surgical intensive care unit. Ultrasound guidance improves the success rate of internal jugular vein cannulation: A prospective, randomized trial. 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. The Texas Medical Center Catheter Study Group. Survey Findings. Literature Findings. . The insertion process includes catheter site selection, insertion under ultrasound guidance, catheter site dressing regimens, securement devices, and use of a CVC insertion bundle. Direct URL citations appear in the printed text and are available in both the HTML and PDF versions of this article. Literature Findings. National Association of Childrens Hospitals and Related Institutions Pediatric Intensive Care Unit Central LineAssociated Bloodstream Infection Quality Transformation Teams. Effect of central line bundle on central lineassociated bloodstream infections in intensive care units. Prospective comparison of ultrasound and CXR for confirmation of central vascular catheter placement. The utility of transthoracic echocardiography to confirm central line placement: An observational study. Iatrogenic injury of vertebral artery resulting in stroke after central venous line insertion. Do not advance the line until you have hold of the end of the wire. 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. There are a variety of catheter, both size and configuration. These values represented moderate to high levels of agreement. Findings from these RCTs are reported separately as evidence. 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.