Netcare Antimicrobial Stewardship and Infection Prevention Study Alliance. Reducing the rate of catheter-associated bloodstream infections in a surgical intensive care unit using the Institute for Healthcare Improvement Central Line Bundle. Positioning the tip of a central venous catheter (CVC) within the superior vena cava (SVC) at or just above the level of the carina is generally considered acceptable for most short-term uses, such as fluid administration or monitoring of central venous pressure. Direct URL citations appear in the printed text and are available in both the HTML and PDF versions of this article. Survey Findings. Impregnated central venous catheters for prevention of bloodstream infection in children (the CATCH trial): A randomised controlled trial. Literature Findings. Supplemental Digital Content is available for this article. Survey Findings. A minimum of five independent RCTs (i.e., sufficient for fitting a random-effects model255) is required for meta-analysis. These recommendations may be adopted, modified, or rejected according to clinical needs and constraints and are not intended to replace local institutional policies. Ultrasonic examination: An alternative to chest radiography after central venous catheter insertion? 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. The consultants and ASA members agree that static ultrasound may also be used when the subclavian or femoral vein is selected. 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. Using the comprehensive unit-based safety program model for sustained reduction in hospital infections. Interventions intended to prevent mechanical trauma or injury associated with central venous access include but are not limited to (1) selection of catheter insertion site; (2) positioning the patient for needle insertion and catheter placement; (3) needle insertion, wire placement, and catheter placement; (4) guidance for needle, guidewire, and catheter placement, and (5) verification of needle, wire, and catheter placement. 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). Usefulness of ultrasonography for the evaluation of catheter misplacement and complications after central venous catheterization. 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. Comparison of alcoholic chlorhexidine and povidoneiodine cutaneous antiseptics for the prevention of central venous catheter-related infection: A cohort and quasi-experimental multicenter study. The epidemiology, antibiograms and predictors of mortality among critically-ill patients with central lineassociated bloodstream infections. Within the text of these guidelines, literature classifications are reported for each intervention using the following: Category A level 1, meta-analysis of randomized controlled trials (RCTs); Category A level 2, multiple RCTs; Category A level 3, a single RCT; Category B level 1, nonrandomized studies with group comparisons; Category B level 2, nonrandomized studies with associative findings; Category B level 3, nonrandomized studies with descriptive findings; and Category B level 4, case series or case reports. Sensitivity to effect measure was also examined. Ultrasound-assisted cannulation of the internal jugular vein: A prospective comparison to the external landmark-guided technique. A prospective, randomized study in critically ill patients using the Oligon Vantex catheter. tip too high: proximal SVC. Trendelenburg position does not increase cross-sectional area of the internal jugular vein predictably. Survey responses for each recommendation are reported using a 5-point scale based on median values from strongly agree to strongly disagree. Meta: An R package for meta-analysis (4.9-4). These guidelines apply to patients undergoing elective central venous access procedures performed by anesthesiologists or healthcare professionals under the direction/supervision of anesthesiologists. 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. 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. Saline flush test: Can bedside sonography replace conventional radiography for confirmation of above-the-diaphragm central venous catheter placement? Opinion surveys were developed by the task force to address each clinical intervention identified in the document. Internal jugular vein cannulation: An ultrasound-guided technique. The central line is placed in your body during a brief procedure. The consultants and ASA members strongly agree with the recommendation to confirm venous access after insertion of a catheter that went over the needle or a thin-wall needle and with the recommendation to not rely on blood color or absence of pulsatile flow for confirming that the catheter or thin-wall needle resides in the vein. An alternative central venous route for cardiac surgery: Supraclavicular subclavian vein catheterization. Advance the guidewire through the needle and into the vein. Simplified point-of-care ultrasound protocol to confirm central venous catheter placement: A prospective study. Evidence categories refer specifically to the strength and quality of the research design of the studies. Central venous catheters coated with minocycline and rifampin for the prevention of catheter-related colonization and bloodstream infections: A randomized, double-blind trial. The authors declare no competing interests. Support was provided solely by the American Society ofAnesthesiologists (Schaumburg, Illinois). 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 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 literature relating to seven evidence linkages contained enough studies with well defined experimental designs and statistical information to conduct formal meta-analyses (table 1). 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. The journey to zero central catheter-associated bloodstream infections: Culture change in an intensive care unit. Eliminating central lineassociated bloodstream infections: A national patient safety imperative. Reduced rates of catheter-associated infection by use of a new silver-impregnated central venous catheter. This approach may not be feasible in emergency circumstances or in the presence of other clinical constraints. ( 21460264) Transition to a PICC line for long-term central access. Ultrasound-guided cannulation of the internal jugular vein: A prospective, randomized study. Standardizing central line safety: Lessons learned for physician leaders. Prepare the centralcatheter kit, and Evidence was obtained from two principal sources: scientific evidence and opinion-based evidence. This update is a revision developed by an ASA-appointed task force of seven members, including five anesthesiologists and two methodologists. 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. 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 incidence of complications after the double-catheter technique for cannulation of the right internal jugular vein in a university teaching hospital. Literature Findings. This may be done in your hospital room or an . Localize the vein by palpating the femoral artery, or use ultrasonography. After review, 729 were excluded, with 284 new studies meeting inclusion criteria. Evaluation of chlorhexidine and silver-sulfadiazine impregnated central venous catheters for the prevention of bloodstream infection in leukaemic patients: A randomized controlled trial. Ties are calculated by a predetermined formula. Of the 484 attempted placements, 472 (97.5%) were primary placements. Statistically significant (P < 0.01) outcomes are designated as either beneficial (B) or harmful (H) for the patient; statistically nonsignificant findings are designated as equivocal (E). 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.) Reduced intravascular catheter infection by antibiotic bonding: A prospective, randomized, controlled trial. Prevention of catheter-related bloodstream infection in critically ill patients using a disinfectable, needle-free connector: A randomized controlled trial. The evidence model below guided the search, providing inclusion and exclusion information regarding patients, procedures, practice settings, providers, clinical interventions, and outcomes. Dressing 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. If you feel any resistance as you advance the guidewire, stop advancing it. 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. The catheter over-the-needle technique may provide more stable venous access if manometry is used for venous confirmation. In most instances, central venous access with ultrasound guidance is considered the standard of care. . Is a routine chest x-ray necessary for children after fluoroscopically assisted central venous access? All opinion-based evidence relevant to each topic was considered in the development of these guidelines. 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. Arterial trauma during central venous catheter insertion: Case series, review and proposed algorithm. Level 2: The literature contains noncomparative observational studies with associative statistics (e.g., correlation, sensitivity, and specificity). Real-time ultrasound-guided subclavian vein cannulation, The influence of the direction of J-tip on the placement of a subclavian catheter: Real time ultrasound-guided cannulation. If you feel any resistance as you advance the guidewire, stop advancing it. The consultants and ASA members strongly agree with the recommendation to confirm venous residence of the wire after the wire is threaded if there is any uncertainty that the catheter or wire resides in the vein, and insertion of a dilator or large-bore catheter may then proceed. Aiming for zero: Decreasing central line associated bacteraemia in the intensive care unit. 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). 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. Sterility In the ED, there are only two ways to place central lines: Full Sterile or Non-Sterile There is no in-between. The consultants and ASA members both agree with the recommendation that dressings containing chlorhexidine may be used in adults, infants, and children unless contraindicated. 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. Advance the guidewire through the needle and into the vein. Decreasing central-lineassociated bloodstream infections in Connecticut intensive care units. 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.