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). 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. For neonates, the consultants and ASA members agree with the recommendation to determine the use of chlorhexidine-containing solutions for skin preparation based on clinical judgment and institutional protocol. Intravascular complications of central venous catheterization by insertion site. Prevention of mechanical trauma or injury: Patient preparation for needle insertion and catheter placement, Awake versus anesthetized patient during insertion, Positive pressure (i.e., mechanical) versus spontaneous ventilation during insertion, Patient position: Trendelenburg versus supine, Surface landmark inspection to identify target vein, Selection of catheter composition (e.g., polyvinyl chloride, polyethylene, Teflon), Selection of catheter type (all types will be compared with each other), Use of a finder (seeker) needle versus no seeker needle (e.g., a wider-gauge access needle), Use of a thin-wall needle versus a cannula over a needle before insertion of a wire for the Seldinger technique, Monitoring for needle, wire, and catheter placement, Ultrasound (including audio-guided Doppler ultrasound), Prepuncture identification of insertion site versus no ultrasound, Guidance during needle puncture and placement versus no ultrasound, Confirmation of venous insertion of needle, Identification of free aspiration of dark (Po2) nonpulsatile blood, Confirmation of venous placement of catheter, Manometry versus direct pressure measurement (via pressure transducer), Timing of x-ray immediately after placement versus postop. Survey Findings. 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). This update is a revision developed by an ASA-appointed task force of seven members, including five anesthesiologists and two methodologists. A prospective randomized trial of an antibiotic- and antiseptic-coated central venous catheter in the prevention of catheter-related infections. Placement of subclavian venous catheters - UpToDate Survey Findings. These guidelines have been endorsed by the Society of Cardiovascular Anesthesiologists and the Society for Pediatric Anesthesia. Cerebral infarct following central venous cannulation. Insert the J-curved end of the guidewire into the introducer needle, with the J curve facing up. Netcare Antimicrobial Stewardship and Infection Prevention Study Alliance. The consultants and ASA members strongly agree with the recommendation to use a chlorhexidine-containing solution for skin preparation in adults, infants, and children. The consultants and ASA members both agree with the recommendation that dressings containing chlorhexidine may be used in adults, infants, and children unless contraindicated. 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. document the position of the line. Literature Findings. How to Safely Place Central Lines in the ED - EMCrit Project These values represented moderate to high levels of agreement. Reduction of central lineassociated bloodstream infection rates in patients in the adult intensive care unit. A randomized trial on chlorhexidine dressings for the prevention of catheter-related bloodstream infections in neutropenic patients. Monitoring central line pressure waveforms and pressures. Comparison of the effect of the Trendelenburg and passive leg raising positions on internal jugular vein size in critically ill patients. Evidence categories refer specifically to the strength and quality of the research design of the studies. Ultrasound-guided supraclavicular central venous catheter tip positioning via the right subclavian vein using a microconvex probe. When available, category A evidence is given precedence over category B evidence for any particular outcome. Multidisciplinary trauma intensive care unit checklist: Impact on infection rates. CLABSI Toolkit - Chapter 3 | The Joint Commission For these guidelines, central venous access is defined as placement of a catheter such that the catheter is inserted into a venous great vessel. Catheter infection risk related to the distance between insertion site and burned area. Randomized, controlled clinical trial of point-of-care limited ultrasonography assistance of central venous cannulation: The Third Sonography Outcomes Assessment Program (SOAP-3) Trial. Accepted for publication May 16, 2019. Where Should the Femoral Central Line Be Placed? Antiseptic-bonded central venous catheters and bacterial colonisation. Ultrasound guidance outcomes were pooled using risk or mean differences (continuous outcomes) for clinical relevance. It can be used to confirm that the catheter or the guidewire has travelled towards the SVC. Survey Findings. Next, place the larger (20- to 22-gauge) needle immediately. Ultrasonography: A novel approach to central venous cannulation. A multicenter intervention to prevent catheter-associated bloodstream infections. Mark, M.D., Durham, North Carolina. Impact of a national multimodal intervention to prevent catheter-related bloodstream infection in the ICU: The Spanish experience. Risk factors of failure and immediate complication of subclavian vein catheterization in critically ill patients. A minimum of 5 supervised successful procedures in both the chest and femoral sites is required (10 total). Managing inadvertent arterial catheterization during central venous access procedures. Incidence of mechanical complications of central venous catheterization using landmark technique: Do not try more than 3 times. Reduction of catheter-related bloodstream infections through the use of a central venous line bundle: Epidemiologic and economic consequences. Matching Michigan Collaboration & Writing Committee. Comparison of triple-lumen central venous catheters impregnated with silver nanoparticles (AgTive). ECG, electrocardiography; TEE, transesophageal echocardiography. 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. The literature is insufficient to evaluate outcomes associated with the routine use of intravenous prophylactic antibiotics. (Chair). The needle insertion path: Insert procedural needles (local anesthetic, finder, and introducer needles) 2 to 4 cm inferior to the inguinal ligament, 1 cm medial to the femoral artery, at a 45 to 60 angle into the skin, and aim toward the umbilicus. A central venous catheter, also called a central line or CVC, is a device that helps you receive treatments for various medical conditions. Effect of central line bundle on central lineassociated bloodstream infections in intensive care units. visualize the tip of the line. Central venous catheter colonization in critically ill patients: A prospective, randomized, controlled study comparing standard with two antiseptic-impregnated catheters. An unexpected image on a chest radiograph. Eradicating central lineassociated bloodstream infections statewide: The Hawaii experience. 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 . 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. Remove the dilator and pass the central line over the Seldinger wire. In most instances, central venous access with ultrasound guidance is considered the standard of care. Example of a Central Venous Catheterization Checklist, https://doi.org/10.1097/ALN.0000000000002864, 2023 American Society of Anesthesiologists Practice Guidelines for Preoperative Fasting: Carbohydrate-containing Clear Liquids with or without Protein, Chewing Gum, and Pediatric Fasting DurationA Modular Update of the 2017 American Society of Anesthesiologists Practice Guidelines for Preoperative Fasting, 2023 American Society of Anesthesiologists Practice Guidelines for Monitoring and Antagonism of Neuromuscular Blockade: A Report by the American Society of Anesthesiologists Task Force on Neuromuscular Blockade, 2022 American Society of Anesthesiologists Practice Guidelines for Management of the Difficult Airway, Practice Guidelines for the Prevention, Detection, and Management of Respiratory Depression Associated with Neuraxial Opioid Administration: An Updated Report by the American Society of Anesthesiologists Task Force on Neuraxial Opioids and the American Society of Regional Anesthesia and Pain Medicine*, Practice Guidelines for Obstetric Anesthesia: An Updated Report by the American Society of Anesthesiologists Task Force on Obstetric Anesthesia and the Society for Obstetric Anesthesia and Perinatology, Practice Guidelines for Perioperative Blood Management: An Updated Report by the American Society of Anesthesiologists Task Force on Perioperative Blood Management*, Practice Advisory for the Perioperative Management of Patients with Cardiac Implantable Electronic Devices: Pacemakers and Implantable CardioverterDefibrillators 2020: An Updated Report by the American Society of Anesthesiologists Task Force on Perioperative Management of Patients with Cardiac Implantable Electronic Devices, Practice Advisory on Anesthetic Care for Magnetic Resonance Imaging: An Updated Report by the American Society of Anesthesiologists Task Force on Anesthetic Care for Magnetic Resonance Imaging, Copyright 2023 American Society of Anesthesiologists. For femoral line CVL, the needle insertion site should be located approximately 1 to 3 cm below the inguinal ligament and 0.5 to 1 cm medial where the femoral artery pulsates. Confirmation of internal jugular guide wire position utilizing transesophageal echocardiography. Catheter-associated bloodstream infection in the pediatric intensive care unit: A multidisciplinary approach. 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. A subclavian artery injury, secondary to internal jugular vein cannulation, is a predictable right-sided phenomenon. A summary of recommendations can be found in appendix 1. Confirmatory xray after US-guided tunneled femoral CVC placement 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. These recommendations may be adopted, modified, or rejected according to clinical needs and constraints and are not intended to replace local institutional policies. 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. Implementation of central venous catheter bundle in an intensive care unit in Kuwait: Effect on central lineassociated bloodstream infections. Literature Findings. 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). Category B: Observational studies or RCTs without pertinent comparison groups may permit inference of beneficial or harmful relationships among clinical interventions and clinical outcomes. Beyond the intensive care unit bundle: Implementation of a successful hospital-wide initiative to reduce central lineassociated bloodstream infections. Placement of a Femoral Venous Catheter | NEJM 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. 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. Assessment of a central lineassociated bloodstream infection prevention program in a burn-trauma intensive care unit. Femoral Central Venous Access Technique - Medscape A controlled study of transesophageal echocardiography to guide central venous catheter placement in congenital heart surgery patients. Four hundred eighty-one (99.4%) placements were technically successful. 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. Missed carotid artery cannulation: A line crossed and lessons learnt. Line infection - EMCrit Project The small . RCTs comparing subclavian and femoral insertion sites report that the femoral site has a higher risk of thrombotic complications in adult patients (Category A2-H evidence)130,131; one RCT131 concludes that thrombosis risk is higher with internal jugular than subclavian catheters (Category A3-H evidence), whereas for femoral versus internal jugular catheters, findings are equivocal (Category A3-E evidence). 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. The consultants and ASA members agree with the recommendations to (1) select the smallest size catheter appropriate for the clinical situation; (2) select a thin-wall needle (i.e., Seldinger) technique versus a catheter-over-the-needle (i.e., modified Seldinger) technique for the subclavian approach; (3) select a thin-wall needle or catheter-over-the-needle technique for the jugular or femoral approach based on the clinical situation and the skill/experience of the operator; and (4) 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 before a dilator or large-bore catheter is threaded. A 20-year retained guidewire: Should it be removed? Prevention of central venous catheter-related infections by using maximal sterile barrier precautions during insertion. Fourth, additional opinions were solicited from random samples of active ASA members. A chest x-ray will be performed immediately following thoracic central line placement to assure line placement and rule out pneumothorax. Five (1.0%) adverse events occurred. Effects of the Trendelenburg position and positive end-expiratory pressure on the internal jugular vein cross-sectional area in children with simple congenital heart defects. Decreasing central-lineassociated bloodstream infections in Connecticut intensive care units. Evaluation of chlorhexidine and silver-sulfadiazine impregnated central venous catheters for the prevention of bloodstream infection in leukaemic patients: A randomized controlled trial.