The femoral vein is the major deep vein of the lower extremity. Allergy to chlorhexidine: Beware of the central venous catheter. 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. Placing the central line. Level 2: The literature contains noncomparative observational studies with associative statistics (e.g., correlation, sensitivity, and specificity). 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. Sometimes (hopefully rarely), the exigencies of time or patient condition will prevent placing a full sterile line. Received from the American Society of Anesthesiologists, Schaumburg, Illinois. The journey to zero central catheter-associated bloodstream infections: Culture change in an intensive care unit. All meta-analyses are conducted by the ASA methodology group. 1), After insertion of a catheter that went over the needle or a thin-wall needle, confirm venous access, If there is any uncertainty that the catheter or wire resides in the vein, confirm venous residence of the wire after the wire is threaded; insertion of a dilator or large-bore catheter may then proceed, After final catheterization and before use, confirm residence of the catheter in the venous system as soon as clinically appropriate####, Confirm the final position of the catheter tip as soon as clinically appropriate*****, Example of a Standardized Equipment Cart for Central Venous Catheterization for Adult Patients. Missed carotid artery cannulation: A line crossed and lessons learnt. The ASA Committee on Standards and Practice Parameters reviews all practice guidelines at the ASA annual meeting and determines update and revision timelines. Posterior cerebral infarction following loss of guide wire. The consultants and ASA members both agree with the recommendation that dressings containing chlorhexidine may be used in adults, infants, and children unless contraindicated. A prospective randomized study. The consultants strongly agree and ASA members agree with the recommendation to use static ultrasound imaging before prepping and draping for prepuncture identification of anatomy to determine vessel localization and patency when the internal jugular vein is selected for cannulation. Nosocomial sepsis: Evaluation of the efficacy of preventive measures in a level-III neonatal intensive care unit. 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.) 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. Central venous catheters revisited: Infection rates and an assessment of the new fibrin analysing system brush. The rate of return was 17.4% (n = 19 of 109). 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. Strict hand hygiene and other practices shortened stays and cut costs and mortality in a pediatric intensive care unit. Society for Pediatric Anesthesia Winter Meeting, April 17, 2010, San Antonio, Texas; Society of Cardiovascular Anesthesia 32nd Annual Meeting, April 25, 2010, New Orleans, Louisiana; and International Anesthesia Research Society Annual Meeting, May 22, 2011, Vancouver, British Columbia, Canada. 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. Literature Findings. Objective To investigate the efficacy of the minimally invasive clamp reduction technique via the anterior approach in the treatment of irreducible intertrochanteric femoral fractures. Survey Findings. A prospective, randomized study in critically ill patients using the Oligon Vantex catheter. I have read and accept the terms and conditions. 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. Use of electronic medical recordenhanced checklist and electronic dashboard to decrease CLABSIs. Intravascular complications of central venous catheterization by insertion site. Prevention of central venous catheter-related bloodstream infection by use of an antiseptic-impregnated catheter: A randomized, controlled trial. 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. Comparison of needle insertion and guidewire placement techniques during internal jugular vein catheterization: The thin-wall introducer needle technique. 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. Matching Michigan: A 2-year stepped interventional programme to minimise central venous catheter-blood stream infections in intensive care units in England. The consultants and ASA members both strongly agree with the recommendation to minimize the number of needle punctures of the skin. Nurse-driven quality improvement interventions to reduce hospital-acquired infection in the NICU. These seven evidence linkages are: (1) antimicrobial catheters, (2) silver impregnated catheters, (3) chlorhexidine and silver-sulfadiazine catheters, (4) dressings containing chlorhexidine, and (5) ultrasound guidance for venipuncture. This may be done in your hospital room or an . . 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 insertion process includes catheter site selection, insertion under ultrasound guidance, catheter site dressing regimens, securement devices, and use of a CVC insertion bundle. Evidence categories refer specifically to the strength and quality of the research design of the studies. 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). 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. This update is a revision developed by an ASA-appointed task force of seven members, including five anesthesiologists and two methodologists. 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. First, consensus was reached on the criteria for evidence. The epidemiology, antibiograms and predictors of mortality among critically-ill patients with central lineassociated bloodstream infections. 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. 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. As the vein is punctured, a flash of dark venous blood into the syringe indicates that the needle tip is within the femoral vein lumen. The femoral vein lies medial to the femoral artery as it runs distal to the inguinal ligament. 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. Randomized, controlled clinical trial of point-of-care limited ultrasonography assistance of central venous cannulation: The Third Sonography Outcomes Assessment Program (SOAP-3) Trial. 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. Central venous line sepsis in the intensive care unit: A study comparing antibiotic coated catheters with plain catheters. There were three (0.6%) technical failures due to previously undiagnosed iliofemoral venous occlusive disease. 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. Anaphylactic shock induced by an antiseptic-coated central venous [correction of nervous] catheter. Survey Findings. No search for gray literature was conducted. Refer to appendix 3 for an example of a checklist or protocol. Cardiac tamponade associated with a multilumen central venous catheter. Comparison of three techniques for internal jugular vein cannulation in infants. Saline flush test: Can bedside sonography replace conventional radiography for confirmation of above-the-diaphragm central venous catheter placement? Once the central line is in place, remove the wire. If you feel any resistance as you advance the guidewire, stop advancing it. A multicentre analysis of catheter-related infection based on a hierarchical model. Advance the guidewire through the needle and into the vein. Monitoring central line pressure waveforms and pressures. 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. Central venous catheter colonization in critically ill patients: A prospective, randomized, controlled study comparing standard with two antiseptic-impregnated catheters. 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 In addition, practice guidelines developed by the American Society of Anesthesiologists (ASA) are not intended as standards or absolute requirements, and their use cannot guarantee any specific outcome. 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. 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. Advance the wire 20 to 30 cm. Central venous access: The effects of approach, position, and head rotation on internal jugular vein cross-sectional area. 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. Example Duties Performed by an Assistant for Central Venous Catheterization. RCTs comparing subclavian and femoral insertion sites report higher rates of catheter colonization at the femoral site (Category A2-H evidence); findings for catheter-related sepsis or catheter-related bloodstream infection are equivocal (Category A2-E evidence).130,131 An RCT finds a higher rate of catheter colonization for internal jugular compared with subclavian insertion (Category A3-H evidence) and for femoral compared with internal jugular insertion (Category A3-H evidence); evidence is equivocal for catheter-related bloodstream infection for either comparison (Category A3-E evidence).131 A nonrandomized comparative study of burn patients reports that catheter colonization and catheter-related bloodstream infection occur more frequently with an insertion site closer to the burn location (Category B1-H evidence).132. 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. 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. Use of ultrasound to evaluate internal jugular vein anatomy and to facilitate central venous cannulation in paediatric patients. Femoral vein cannulation performed by residents: A comparison between ultrasound-guided and landmark technique in infants and children undergoing cardiac surgery. Literature Findings. visualize the tip of the line. Ultrasonic examination: An alternative to chest radiography after central venous catheter insertion? A multitiered strategy of simulation training, kit consolidation, and electronic documentation is associated with a reduction in central lineassociated bloodstream infections. 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. Peripheral IV insertion and care. For membership respondents, the survey rate of return was 8% (n = 393 of 5,000) members. Use full sterile dress. Of the 484 attempted placements, 472 (97.5%) were primary placements. 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. The consultants and ASA members strongly agree with the recommendation to use a chlorhexidine-containing solution for skin preparation in adults, infants, and children. Aiming for zero: Decreasing central line associated bacteraemia in the intensive care unit. 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. Is a routine chest x-ray necessary for children after fluoroscopically assisted central venous access? Contamination of central venous catheters in immunocompromised patients: A comparison between two different types of central venous catheters. 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. Survey Findings. For these guidelines, central venous access is defined as placement of a catheter such that the catheter is inserted into a venous great vessel. Order a chest x-ray to check for line position and pneumothorax if a jugular or subclavian line has . 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. These updated guidelines were developed by means of a five-step process. A randomized trial comparing povidoneiodine to a chlorhexidine gluconate-impregnated dressing for prevention of central venous catheter infections in neonates. 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). Refer to appendix 4 for an example of a list of duties performed by an assistant. Real-time ultrasound-guided catheterisation of the internal jugular vein: A prospective comparison with the landmark technique in critical care patients. Reduction of central lineassociated bloodstream infection rates in patients in the adult intensive care unit. 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. These large diameter central veins are located universally near a large artery. 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. Stepwise introduction of the Best Care Always central-lineassociated bloodstream infection prevention bundle in a network of South African hospitals. Central venous line placement is typically performed at four sites in the body: . A minimum of five independent RCTs (i.e., sufficient for fitting a random-effects model255) is required for meta-analysis. A prospective randomised trial comparing insertion success rate and incidence of catheterisation-related complications for subclavian venous catheterisation using a thin-walled introducer needle or a catheter-over-needle technique. Heterogeneity was quantified with I2 and prediction intervals estimated (see table 1). Decreasing catheter-related bloodstream infections in the intensive care unit: Interventions in a medical center in central Taiwan. 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. 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. Fourth, additional opinions were solicited from random samples of active ASA members. When obtaining central venous access in the femoral vein, the key anatomical landmarks to identify in the inguinal-femoral region are the inguinal ligament and the femoral artery pulsation. . Catheter infection: A comparison of two catheter maintenance techniques. Prevention of central venous catheter related infections with chlorhexidine gluconate impregnated wound dressings: A randomized controlled trial. Comparison of an ultrasound-guided technique. 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. These evidence categories are further divided into evidence levels. Aseptic techniques using an existing central venous catheter for injection or aspiration consist of (1) wiping the port with an appropriate antiseptic, (2) capping stopcocks or access ports, and (3) use of needleless catheter connectors or access ports. 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). 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. Editorials, letters, and other articles without data were excluded. Single-operator ultrasound-guided central venous catheter insertion verifies proper tip placement. Level 4: The literature contains case reports. Ultrasound-guided supraclavicular central venous catheter tip positioning via the right subclavian vein using a microconvex probe. 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. Antiseptic-bonded central venous catheters and bacterial colonisation. An evaluation with ultrasound. Publications identified by task force members were also considered. Comparison of silver-impregnated with standard multi-lumen central venous catheters in critically ill patients. 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. 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. Five (1.0%) adverse events occurred. Opinion surveys were developed by the task force to address each clinical intervention identified in the document. Assessment of a central lineassociated bloodstream infection prevention program in a burn-trauma intensive care unit. Literature 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. If a physician successfully performs the 5 supervised lines in one site, they are independent for that site only. Literature Findings. Is traditional reading of the bedside chest radiograph appropriate to detect intraatrial central venous catheter position? Do not force the wire; it should slide smoothly. Only studies containing original findings from peer-reviewed journals were acceptable. Decreasing central-lineassociated bloodstream infections in Connecticut intensive care units. Prevention of catheter-related bloodstream infection in critically ill patients using a disinfectable, needle-free connector: A randomized controlled trial. 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. The central line is placed in your body during a brief procedure. Because not all studies of dressings reported event rates, relative risks or hazard ratios (recognizing they approximate relative risks) were pooled.
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