Reduction of catheter-related infections in neutropenic patients: A prospective controlled randomized trial using a chlorhexidine and silver sulfadiazine-impregnated central venous catheter. Level 1: The literature contains a sufficient number of RCTs to conduct meta-analysis, and meta-analytic findings from these aggregated studies are reported as evidence. Literature Findings. Choice of route for central venous cannulation: Subclavian or internal jugular vein? The consultants are equivocal and ASA members agree that when using the catheter-over-the-needle technique, confirmation that the wire resides in the vein may not be needed (1) if the catheter enters the vein easily and manometry or pressure-waveform measurement provides unambiguous confirmation of venous location of the catheter and (2) if the wire passes through the catheter and enters the vein without difficulty. Trendelenburg position, head elevation and a midline position optimize right internal jugular vein diameter. Ultrasound-guided central venous cannulation is superior to quick-look ultrasound and landmark methods among inexperienced operators: A prospective randomized study. 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. 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). Aiming for zero: Decreasing central line associated bacteraemia in the intensive care unit. Pediatric Patients: o Optimal catheter type and site selection in children is more co mplex, with the internal jugular vein or femoral vein most commonly used. Eliminating arterial injury during central venous catheterization using manometry. A minimum of five independent RCTs (i.e., sufficient for fitting a random-effects model255) is required for meta-analysis. Use real-time ultrasound guidance for vessel localization and venipuncture when the internal jugular vein is selected for cannulation (see fig. Advance the wire 20 to 30 cm. Insert the J-curved end of the guidewire into the introducer needle, with the J curve facing up. Severe anaphylactic reaction due to a chlorhexidine-impregnated central venous catheter. Survey findings from task forceappointed expert consultants and a random sample of the ASA membership are fully reported in the text of these guidelines. 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). Effects of varying entry points and trendelenburg positioning degrees in internal jugular vein area measurements of newborns. Central line placement is a common . Survey Findings. Address correspondence to the American Society of Anesthesiologists: 1061 American Lane, Schaumburg, Illinois 60173. If you feel any resistance as you advance the guidewire, stop advancing it. Arterial misplacement of large-caliber cannulas during jugular vein catheterization: Case for surgical management. Practice guidelines are subject to revision as warranted by the evolution of medical knowledge, technology, and practice. Comparison of alcoholic chlorhexidine and povidoneiodine cutaneous antiseptics for the prevention of central venous catheter-related infection: A cohort and quasi-experimental multicenter study. 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. The consultants and ASA members agree that when feasible, real-time ultrasound may be used when the subclavian or femoral vein is selected. Impact of a national multimodal intervention to prevent catheter-related bloodstream infection in the ICU: The Spanish experience. Do not force the wire; it should slide smoothly. The consultants and ASA members agree with the recommendation to use skin preparation solutions containing alcohol unless contraindicated. Target CLAB Zero: A national improvement collaborative to reduce central lineassociated bacteraemia in New Zealand intensive care units. The accuracy of electrocardiogram-controlled central line placement. Implementation of central venous catheter bundle in an intensive care unit in Kuwait: Effect on central lineassociated bloodstream infections. Implementing a multifaceted intervention to decrease central lineassociated bloodstream infections in SEHA (Abu Dhabi Health Services Company) intensive care units: The Abu Dhabi experience. Prepare the centralcatheter kit, and Supported by the American Society of Anesthesiologists and developed under the direction of the Committee on Standards and Practice Parameters, Jeffrey L. Apfelbaum, M.D. 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. Effectiveness of a programme to reduce the burden of catheter-related bloodstream infections in a tertiary hospital. 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. New York State Regional Perinatal Care Centers. 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. Comparison of three techniques for internal jugular vein cannulation in infants. 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. The long-term effect of bundle care for catheter-related blood stream infection: 5-year follow-up. Literature Findings. 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 ASA Committee on Standards and Practice Parameters reviews all practice guidelines at the ASA annual meeting and determines update and revision timelines. Support was provided solely by the American Society ofAnesthesiologists (Schaumburg, Illinois). In 2017, the ASA Committee on Standards and Practice Parameters requested that these guidelines be updated. There are many uses of these catheters. Elective central venous access procedures, Emergency central venous access procedures, Any setting where elective central venous access procedures are performed, Providers working under the direction of anesthesiologists, Individuals who do not perform central venous catheterization, Selection of a sterile environment (e.g., operating room) for elective central venous catheterization, Availability of a standardized equipment set (e.g., kit/cart/set of tools) for central venous catheterization, Use of a trained assistant for central venous catheterization, Use of a checklist for central venous catheter placement and maintenance, Washing hands immediately before placement, Sterile gown, gloves, mask, cap for the operators, Shaving hair versus clipping hair versus no hair removal, Skin preparation with versus without alcohol, Antibiotic-coated catheters versus no coating, Silver-impregnated catheters versus no coating, Heparin-coated catheters versus no coating, Antibiotic-coated or silver-impregnated catheter cuffs, Selecting an insertion site that is not contaminated or potentially contaminated (e.g., burned or infected skin, a site adjacent to a tracheostomy site), Long-term versus short-term catheterization, Frequency of assessing the necessity of retaining access, Frequency of insertion site inspection for signs of infection, At specified time intervals versus no specified time intervals, One specified time interval versus another time interval, Changing over a wire versus a new catheter at a new site, Injecting or aspirating using an existing central venous catheter, Aseptic techniques (e.g., wiping port with alcohol). 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. Efficacy of silver-coating central venous catheters in reducing bacterial colonization. Publications identified by task force members were also considered. Survey Findings. 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. For neonates, the consultants and ASA members agree with the recommendation to determine the use of transparent or sponge dressings containing chlorhexidine based on clinical judgment and institutional protocol. Refer to appendix 4 for an example of a list of duties performed by an assistant. 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. Additional caution should be exercised in patients requiring femoral vein catheterization who have had prior arterial surgery. 2012 Emery A. Rovenstine Memorial Lecture: The genesis, development, and future of the American Society of Anesthesiologists evidence-based practice parameters. 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. 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. Category A: RCTs report comparative findings between clinical interventions for specified outcomes. 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. Central venous cannulation: Are routine chest radiographs necessary after B-mode and colour Doppler sonography check? Accepted studies from the previous guidelines were also rereviewed, covering the period of January 1, 1971, through June 31, 2011. NICE guidelines for central venous catheterization in children: Is the evidence base sufficient? Evaluation and classification of evidence for the ASA clinical practice guidelines, Millers Anesthesia. 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. Anaphylactic shock induced by an antiseptic-coated central venous [correction of nervous] catheter. The literature is insufficient to evaluate the effect of the physical environment for aseptic catheter insertion, availability of a standardized equipment set, or the use of an assistant on outcomes associated with central venous catheterization. Insert the introducer needle with negative pressure until venous blood is aspirated. 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. Images in cardiovascular medicine: Percutaneous retrieval of a lost guidewire that caused cardiac tamponade. This approach may not be feasible in emergency circumstances or in the presence of other clinical constraints. Fourth, additional opinions were solicited from random samples of active ASA members. . The syringe was removed and a guidewire was advanced through the needle into the femoral artery. The tube travels through one or more veins until the tip reaches the large vein that empties into your heart ( vena cava ). Evidence was obtained from two principal sources: scientific evidence and opinion-based evidence. Methods for confirming that the wire resides in the vein include, but are not limited to, ultrasound (identification of the wire in the vein) or transesophageal echocardiography (identification of the wire in the superior vena cava or right atrium), continuous electrocardiography (identification of narrow-complex ectopy), or fluoroscopy. 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. The type of catheter and location of placement will depend on the reason for it's placement. 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. Reduced intravascular catheter infection by antibiotic bonding: A prospective, randomized, controlled trial. Reducing PICU central lineassociated bloodstream infections: 3-year results. The consultants and ASA members strongly agree with the following recommendations: (1) after final catheterization and before use, confirm residence of the catheter in the venous system as soon as clinically appropriate; (2) confirm the final position of the catheter tip as soon as clinically appropriate; (3) for central venous catheters placed in the operating room, perform a chest radiograph no later than the early postoperative period to confirm the position of the catheter tip; (4) verify that the wire has not been retained in the vascular system at the end of the procedure by confirming the presence of the removed wire in the procedural field; and (5) if the complete guidewire is not found in the procedural field, order chest radiography to determine whether the guidewire has been retained in the patients vascular system. The consultants and ASA members both agree with the recommendation that dressings containing chlorhexidine may be used in adults, infants, and children unless contraindicated. 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. The needle was exchanged over the wire for an arterial . 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. Anaphylaxis to chlorhexidine in a chlorhexidine-coated central venous catheter during general anaesthesia. The femoral vein is the major deep vein of the lower extremity. This line is placed into the vein that runs behind the collarbone. There are a variety of catheter, both size and configuration. Stepwise introduction of the Best Care Always central-lineassociated bloodstream infection prevention bundle in a network of South African hospitals. A multicentre analysis of catheter-related infection based on a hierarchical model. Approved by the American Society of Anesthesiologists House of Delegates on October 23, 2019. Effect of central line bundle on central lineassociated bloodstream infections in intensive care units. Eliminating catheter-related bloodstream infections in the intensive care unit. 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. The consultants strongly agree and ASA members agree with the recommendation to determine the use of sutures, staples, or tape for catheter fixation on a local or institutional basis. Level 2: The literature contains noncomparative observational studies with associative statistics (e.g., correlation, sensitivity, and specificity). The catheter over-the-needle technique may provide more stable venous access if manometry is used for venous confirmation. 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. Reduced colonization and infection with miconazole-rifampicin modified central venous catheters: A randomized controlled clinical trial. First, consensus was reached on the criteria for evidence. Level 4: The literature contains case reports. The incidence of complications after the double-catheter technique for cannulation of the right internal jugular vein in a university teaching hospital. A randomized trial comparing povidoneiodine to a chlorhexidine gluconate-impregnated dressing for prevention of central venous catheter infections in neonates. 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. Matching Michigan: A 2-year stepped interventional programme to minimise central venous catheter-blood stream infections in intensive care units in England. Comparison of silver-impregnated with standard multi-lumen central venous catheters in critically ill patients. The effect of position and different manoeuvres on internal jugular vein diameter size.