Is traditional reading of the bedside chest radiograph appropriate to detect intraatrial central venous catheter position? No difference in catheter sepsis between standard and antiseptic central venous catheters: A prospective randomized trial. Statewide NICU central-lineassociated bloodstream infection rates decline after bundles and checklists. Reduction of central lineassociated bloodstream infection rates in patients in the adult intensive care unit. Small study effects (including potential publication bias) were explored by examining forest and funnel plots, regression tests, trim-and-fill results, and limit meta-analysis. Impact of a prevention strategy targeted at vascular-access care on incidence of infections acquired in intensive care. In this document, 249 are referenced, with a complete bibliography of articles used to develop these guidelines, organized by section, available as Supplemental Digital Content 3 (http://links.lww.com/ALN/C8). Prospective comparison of ultrasound and CXR for confirmation of central vascular catheter placement. 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 Mark, M.D., Durham, North Carolina. Central Line Insertion Care Team Checklist | Agency for Healthcare 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. 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. The procedure to place a femoral central line is as follows: You will have to lie down on your back for this procedure. If a physician successfully performs the 5 supervised lines in one site, they are independent for that site only. Using the comprehensive unit-based safety program model for sustained reduction in hospital infections. These guidelines apply to patients undergoing elective central venous access procedures performed by anesthesiologists or healthcare professionals under the direction/supervision of anesthesiologists. Comparison of three techniques for internal jugular vein cannulation in infants. An evaluation with ultrasound. Microbiological evaluation of central venous catheter administration hubs. Monitoring central line pressure waveforms and pressures. 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. How To Do Femoral Vein Cannulation, Ultrasound-Guided 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). Femoral lines are usually used only as provisional access because they have a high risk of infection. Fifth, all available information was used to build consensus to finalize the guidelines. Assessment of a central lineassociated bloodstream infection prevention program in a burn-trauma intensive care unit. 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. Failure of antiseptic bonding to prevent central venous catheter-related infection and sepsis. Chlorhexidine-related refractory anaphylactic shock: A case successfully resuscitated with extracorporeal membrane oxygenation. Prospective comparison of two management strategies of central venous catheters in burn patients. Literature Findings. Misplacement of a guidewire diagnosed by transesophageal echocardiography. 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. This description of the venous great vessels is consistent with the venous subset for central lines defined by the National Healthcare Safety Network. Multimodal interventions for bundle implementation to decrease central lineassociated bloodstream infections in adult intensive care units in a teaching hospital in Taiwan, 20092013. 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.. Missed carotid artery cannulation: A line crossed and lessons learnt. Advance the wire 20 to 30 cm. Findings from these RCTs are reported separately as evidence. Survey 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. 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. Please read and accept the terms and conditions and check the box to generate a sharing link. 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 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. Level 1: The literature contains nonrandomized comparisons (e.g., quasiexperimental, cohort [prospective or retrospective], or case-control research designs) with comparative statistics between clinical interventions for a specified clinical outcome. Survey Findings. Case reports of adult patients with arterial puncture by a large-bore catheter/vessel dilator during attempted central venous catheterization indicate severe complications (e.g., cerebral infarction, arteriovenous fistula, hemothorax) after immediate catheter removal (Category B4-H evidence)172,176,253; complications are uncommonly reported for adult patients whose catheters were left in place before surgical consultation and repair (Category B4-E evidence).172,176,254. Although observational studies report that Trendelenburg positioning (i.e., head down from supine) increases the right internal jugular vein diameter or cross-sectional area in adult volunteers (Category B2-B evidence),157161 findings are equivocal for studies enrolling adult patients (Category B2-E evidence).158,162164 Observational studies comparing the Trendelenburg position and supine position in pediatric patients report increased right internal jugular vein diameter or cross-sectional area (Category B2-B evidence),165167 and one observational study of newborns reported similar findings (Category B2-B evidence).168 The literature is insufficient to evaluate whether Trendelenburg positioning improves insertion success rates or decreases the risk of mechanical complications. Practice guidelines are subject to revision as warranted by the evolution of medical knowledge, technology, and practice. Elimination of central-venous-catheterrelated bloodstream infections from the intensive care unit. Risk factors for catheter-related bloodstream infection: A prospective multicenter study in Brazilian intensive care units. subclavian vein (left or right) assessing position. A sonographically guided technique for central venous access. If possible, this site is recommended by United States guidelines. The consultants and ASA members agree with the recommendation to use an assistant during placement of a central venous catheter. A controlled study of transesophageal echocardiography to guide central venous catheter placement in congenital heart surgery patients. Catheter-associated bloodstream infection in the pediatric intensive care unit: A multidisciplinary approach. 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 catheters coated with minocycline and rifampin for the prevention of catheter-related colonization and bloodstream infections: A randomized, double-blind trial. Trendelenburg position does not increase cross-sectional area of the internal jugular vein predictably. The accuracy of electrocardiogram-controlled central line placement. Reduction of catheter-related bloodstream infections through the use of a central venous line bundle: Epidemiologic and economic consequences. American Society of Anesthesiologists Task Force on Central Venous A. 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. The literature is insufficient to evaluate the efficacy of transparent bioocclusive dressings to reduce the risk of infection. The effect of hand hygiene compliance on hospital-acquired infections in an ICU setting in a Kuwaiti teaching hospital. 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. 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. A total of 3 supervised re-wires is required prior to performing a rewire . This line is placed in a large vein in the groin. Comparison of silver-impregnated with standard multi-lumen central venous catheters in critically ill patients. Chlorhexidine and gauze and tape dressings for central venous catheters: A randomized clinical trial. Central venous catheters are placed typically in one of 3 large central veins: the internal jugular vein (IJ), subclavian vein (SCL), or femoral vein. Advance the guidewire through the needle and into the vein. Impact of a national multimodal intervention to prevent catheter-related bloodstream infection in the ICU: The Spanish experience. Literature exclusion criteria (except to obtain new citations): For the systematic review, potentially relevant clinical studies were identified via electronic and manual searches. Significant reduction of central-line associated bloodstream infections in a network of diverse neonatal nurseries. I have read and accept the terms and conditions. Use real-time ultrasound guidance for vessel localization and venipuncture when the internal jugular vein is selected for cannulation (see fig. An intervention to decrease catheter-related bloodstream infections in the ICU. A multicentre analysis of catheter-related infection based on a hierarchical model. An unexpected image on a chest radiograph. Comparison of the effect of the Trendelenburg and passive leg raising positions on internal jugular vein size in critically ill patients. Evaluation and classification of evidence for the ASA clinical practice guidelines, Millers Anesthesia. French Catheter Study Group in Intensive Care. Literature Findings. 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. Effect of a second-generation venous catheter impregnated with chlorhexidine and silver sulfadiazine on central catheter-related infections: A randomized, controlled trial. Confirmation of internal jugular guide wire position utilizing transesophageal echocardiography. The effects of the Trendelenburg position and the Valsalva manoeuvre on internal jugular vein diameter and placement in children. Meta-analyses of RCTs comparing real-time ultrasound-guided venipuncture of the internal jugular with an anatomical landmark approach report higher first insertion attempt success rates,186197 higher overall success rates,186,187,189192,194204 lower rates of arterial puncture,186188,190201,203,205 and fewer insertion attempts (Category A1-B evidence).188,190,191,194197,199,200,203205 RCTs also indicate reduced access time or times to cannulation with ultrasound compared with a landmark approach (Category A2-B evidence).188,191,194196,199,200,202205, For the subclavian vein, RCTs report fewer insertion attempts with real-time ultrasound-guided venipuncture (Category A2-B evidence),206,207 and higher overall success rates (Category A2-B evidence).206208 When compared with a landmark approach, findings are equivocal for arterial puncture207,208 and hematoma (Category A2-E evidence).207,208 For the femoral vein, an RCT reports a higher first-attempt success rate and fewer needle passes with real-time ultrasound-guided venipuncture compared with the landmark approach in pediatric patients (Category A3-B evidence).209, Meta-analyses of RCTs comparing static ultrasound with a landmark approach yields equivocal evidence for improved overall success for internal jugular insertion (Category A1-E evidence),190,202,210212 overall success irrespective of insertion site (Category A1-E evidence),182,190,202,210212 or impact on arterial puncture rates (Category A1-E evidence).190,202,210212 RCTs comparing static ultrasound with a landmark approach for locating the internal jugular vein report a higher first insertion attempt success rate with static ultrasound (Category A3-B evidence).190,212 The literature is equivocal regarding overall success for subclavian vein access (Category A3-E evidence)182 or femoral vein access when comparing static ultrasound to the landmark approach (Category A3-E evidence).202.