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No search for gray literature was conducted. Fluoroscopy-guided subclavian vein catheterization in 203 children with hematologic disease. 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. This line is placed in a large vein in the groin. Decreasing catheter colonization through the use of an antiseptic-impregnated catheter: A continuous quality improvement project. 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. Randomized, controlled clinical trial of point-of-care limited ultrasonography assistance of central venous cannulation: The Third Sonography Outcomes Assessment Program (SOAP-3) Trial. Prevention of intravascular catheter-related infection with newer chlorhexidine-silver sulfadiazinecoated catheters: A randomized controlled trial. Of the respondents, 82% indicated that the guidelines would have no effect on the amount of time spent on a typical case, and 17.6% indicated that there would be an increase of the amount of time spent on a typical case with the implementation of these guidelines. 1)##, When feasible, real-time ultrasound may be used when the subclavian or femoral vein is selected, 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, Static ultrasound may also be used when the subclavian or femoral vein is selected, After insertion of a catheter that went over the needle or a thin-wall needle, confirm venous access***, Do not rely on blood color or absence of pulsatile flow for confirming that the catheter or thin-wall needle resides in the vein, When using the thin-wall needle technique, confirm venous residence of the wire after the wire is threaded, When using the catheter-over-the-needle technique, confirmation that the wire resides in the vein may not be needed (1) when the catheter enters the vein easily and manometry or pressure-waveform measurement provides unambiguous confirmation of venous location of the catheter and (2) when the wire passes through the catheter and enters the vein without difficulty, 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, 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, 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, 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, Literature Findings. Use full sterile dress. Opinion surveys were developed by the task force to address each clinical intervention identified in the document. Approved by the American Society of Anesthesiologists House of Delegates on October 23, 2019. In 2017, the ASA Committee on Standards and Practice Parameters requested that these guidelines be updated. The evidence model below guided the search, providing inclusion and exclusion information regarding patients, procedures, practice settings, providers, clinical interventions, and outcomes. Fatal respiratory obstruction following insertion of a central venous line. Hospital-wide multidisciplinary, multimodal intervention programme to reduce central venous catheter-associated bloodstream infection. subclavian vein (left or right) assessing position. Survey Findings. Transthoracic echocardiographic guidance for obtaining an optimal insertion length of internal jugular venous catheters in infants. The consultants strongly agree and ASA members agree with the recommendation to use a checklist or protocol for placement and maintenance of central venous catheters. 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. 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. 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. Prospective randomised trial of povidoneiodine, alcohol, and chlorhexidine for prevention of infection associated with central venous and arterial catheters. A multidisciplinary approach to reduce central lineassociated bloodstream infections. Ultrasound localization of central vein catheter and detection of postprocedural pneumothorax: An alternative to chest radiography. Ultrasound as a screening tool for central venous catheter positioning and exclusion of pneumothorax. A prospective randomized study to compare ultrasound-guided with nonultrasound-guided double lumen internal jugular catheter insertion as a temporary hemodialysis access. If a physician successfully performs the 5 supervised lines in one site, they are independent for that site only. Impact of a national multimodal intervention to prevent catheter-related bloodstream infection in the ICU: The Spanish experience. 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. The consultants and ASA members agree that when feasible, real-time ultrasound may be used when the subclavian or femoral vein is selected. This is a particular concern during peripheral insertion or insertion of catheters via the axillary vein or subclavian vein, when ultrasound scanning of the internal jugular vein may rule out a 'wrong' upward direction of the catheter or wire. 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. 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. These large diameter central veins are located universally near a large artery. Literature Findings. The effect of process control on the incidence of central venous catheter-associated bloodstream infections and mortality in intensive care units in Mexico. Ideally the distal end of a CVC should be orientated vertically within the SVC. 1)****, Use real-time ultrasound guidance for vessel localization and venipuncture when the internal jugular vein is selected for cannulation (see fig. The femoral vein is the major deep vein of the lower extremity. Publications identified by task force members were also considered. Palpating the femoral pulse throughout the procedure, the introducer needle was inserted into the femoral artery. 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 tube travels through one or more veins until the tip reaches the large vein that empties into your heart ( vena cava ). Localize the vein by palpating the femoral artery, or use ultrasonography. The type of catheter and location of placement will depend on the reason for it's placement. hemorrhage, hematoma formation, and pneumothorax during central line placement. Proper maintenance of CVCs includes disinfection of catheter hubs, connectors, and injection ports and changing dressings over the site every two days for gauze . A central venous catheter, also called a central line or CVC, is a device that helps you receive treatments for various medical conditions. 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. Refer to appendix 3 for an example of a checklist or protocol. . Location of the central venous catheter tip with bedside ultrasound in young children: Can we eliminate the need for chest radiography? Pacing catheters. 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. 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. Nursing care. Cardiac tamponade associated with a multilumen central venous catheter. The consultants and ASA members both strongly agree with the recommendations to use transparent bioocclusive dressings to protect the site of central venous catheter insertion from infection. The rapid atrial swirl sign for assessing central venous catheters: Performance by medical residents after limited training. Prepare the centralcatheter kit, and 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. Conflict-of-interest documentation regarding current or potential financial and other interests pertinent to the practice guideline were disclosed by all task force members and managed. Implementation of central lineassociated bloodstream infection prevention bundles in a surgical intensive care unit using peer tutoring. Support was provided solely by the American Society ofAnesthesiologists (Schaumburg, Illinois). The literature is insufficient to evaluate whether catheter fixation with sutures, staples, or tape is associated with a higher risk for catheter-related infections. Saline flush test: Can bedside sonography replace conventional radiography for confirmation of above-the-diaphragm central venous catheter placement? 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. Effects of varying entry points and trendelenburg positioning degrees in internal jugular vein area measurements of newborns. Central venous access: The effects of approach, position, and head rotation on internal jugular vein cross-sectional area. The literature is insufficient to evaluate the efficacy of transparent bioocclusive dressings to reduce the risk of infection. 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. Refer to appendix 4 for an example of a list of duties performed by an assistant. = 100%; (5) selection of antiseptic solution for skin preparation = 100%; (6) catheters with antibiotic or antiseptic coatings/impregnation = 68.5%; (7) catheter insertion site selection (for prevention of infectious complications) = 100%; (8) catheter fixation methods (sutures, staples, tape) = 100%; (9) insertion site dressings = 100%; (10) catheter maintenance (insertion site inspection, changing catheters) = 100%; (11) aseptic techniques using an existing central line for injection or aspiration = 100%; (12) selection of catheter insertion site (for prevention of mechanical trauma) = 100%; (13) positioning the patient for needle insertion and catheter placement = 100%; (14) needle insertion, wire placement, and catheter placement (catheter size, type) = 100%; (15) guiding needle, wire, and catheter placement (ultrasound) = 100%; (16) verifying needle, wire, and catheter placement = 100%; (17) confirmation of final catheter tip location = 89.5%; and (18) management of trauma or injury arising from central venous catheterization = 100%. Peripheral IV insertion and care. A 20-year retained guidewire: Should it be removed? : Prospective randomized comparison with landmark-guided puncture in ventilated patients. Level 3: The literature contains noncomparative observational studies with descriptive statistics (e.g., frequencies, percentages). These guidelines have been endorsed by the Society of Cardiovascular Anesthesiologists and the Society for Pediatric Anesthesia. The consultants and ASA members agree that static ultrasound may also be used when the subclavian or femoral vein is selected. Survey responses for each recommendation are reported using a 5-point scale based on median values from strongly agree to strongly disagree. Internal jugular vein cannulation: An ultrasound-guided technique. Beyond the intensive care unit bundle: Implementation of a successful hospital-wide initiative to reduce central lineassociated bloodstream infections. Effectiveness of a programme to reduce the burden of catheter-related bloodstream infections in a tertiary hospital. Four hundred eighty-one (99.4%) placements were technically successful. Comparison of the effect of the Trendelenburg and passive leg raising positions on internal jugular vein size in critically ill patients. 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. Aspirate and flush all lumens and re clamp and apply lumen caps. These guidelines are intended for use by anesthesiologists and individuals under the supervision of an anesthesiologist. Analyses were conducted in R version 3.5.3256 using the Meta257 and Metasens258 packages. Links to the digital files are provided in the HTML text of this article on the Journals Web site (www.anesthesiology.org). Advance the guidewire through the needle and into the vein. Matching Michigan Collaboration & Writing Committee. Comparison of alcoholic chlorhexidine and povidoneiodine cutaneous antiseptics for the prevention of central venous catheter-related infection: A cohort and quasi-experimental multicenter study. Risk factors for catheter-related bloodstream infection: A prospective multicenter study in Brazilian intensive care units. ECG, electrocardiography; TEE, transesophageal echocardiography. Identical surveys were distributed to expert consultants and a random sample of members of the participating organizations. Anesthesia was achieved using 1% lidocaine. Impact of two bundles on central catheter-related bloodstream infection in critically ill patients. 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. Two observational studies indicate that ultrasound can confirm venous placement of the wire before dilation or final catheterization (Category B3-B evidence).214,215 Observational studies also demonstrate that transthoracic ultrasound can confirm residence of the guidewire in the venous system (Category B3-B evidence).216219 One observational study indicates that transesophageal echocardiography can be used to identify guidewire position (Category B3-B evidence),220 and case reports document similar findings (Category B4-B evidence).221,222, Observational studies indicate that transthoracic ultrasound can confirm correct catheter tip position (Category B2-B evidence).216,217,223240 Observational studies also indicate that fluoroscopy241,242 and chest radiography243,244 can identify the position of the catheter (Category B2-B evidence). Survey Findings. No difference in catheter sepsis between standard and antiseptic central venous catheters: A prospective randomized trial. Management of trauma or injury arising from central venous catheterization: Management of arterial cannulation, arterial injury, or cerebral embolization, Pulling out a catheter from the carotid artery versus the subclavian artery, Immediate removal versus retaining catheter until a vascular surgery consult is obtained, Management of catheter or wire shearing or loss, Management of hemo/pneumothorax; retroperitoneal bleeding after femoral catheterization, Management of wire knot, wire, or catheter that will not come out, Management of thromboembolism during removal, Floatation and residence (i.e., maintenance) issues of a pulmonary artery catheter, Central venous catheters versus other methods of assessing volume status or presence of tamponade/pericarditis (e.g., pulse pressure variability and echo), Clinical indications for placement of central venous catheters, Detection and treatment of infectious complications, Education, training, and certification of providers, Monitoring central line pressure waveforms and pressures, 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, etc. 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. 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. For membership respondents, the survey rate of return was 8% (n = 393 of 5,000) members. Prepare the skin with chlorhexidine, and cover the area with a sterile drape. 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 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. 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. trace the line from its insertion towards the heart. Literature Findings. Decreasing PICU catheter-associated bloodstream infections: NACHRIs quality transformation efforts. An intervention to decrease catheter-related bloodstream infections in the ICU. A collaborative, systems-level approach to eliminating healthcare-associated MRSA, central-lineassociated bloodstream infections, ventilator-associated pneumonia, and respiratory virus infections. The consultants and ASA members strongly agree with the recommendations to (1) determine catheter insertion site selection based on clinical need; (2) select an insertion site that is not contaminated or potentially contaminated (e.g., burned or infected skin, inguinal area, adjacent to tracheostomy, or open surgical wound); and (3) select an upper body insertion site when possible to minimize the risk of infection in adults. 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. 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. Random-effects models were fitted with inverse variance weighting using the DerSimonian and Laird estimate of between-study variance. A chest x-ray will be performed immediately following thoracic central line placement to assure line placement and rule out pneumothorax. 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.