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The consultants agree and ASA members strongly agree that the number of insertion attempts should be based on clinical judgment and that the decision to place two catheters in a single vein should be made on a case-by-case basis. 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. Reduced intravascular catheter infection by antibiotic bonding: A prospective, randomized, controlled trial. Category A: RCTs report comparative findings between clinical interventions for specified outcomes. The American Society of Anesthesiologists practice parameter methodology. Comparison of central venous catheterization with and without ultrasound guide. 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. Antimicrobial durability and rare ultrastructural colonization of indwelling central catheters coated with minocycline and rifampin. Ultrasound localization of central vein catheter and detection of postprocedural pneumothorax: An alternative to chest radiography. Consultants were drawn from the following specialties where central venous access is a concern: anesthesiology (97% of respondents) and critical care (3% of respondents). Advance the wire 20 to 30 cm. 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. Power analysis for random-effects meta-analysis. Bibliographic database searches included PubMed and EMBASE. Internal jugular vein diameter in pediatric patients: Are the J-shaped guidewire diameters bigger than internal jugular vein? 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. Central venous catheter colonization and catheter-related bloodstream infections in critically ill patients: A comparison between standard and silver-integrated catheters. COPD, chronic obstructive pulmonary disease; CPR, cardiopulmonary resuscitation; ECG, electrocardiography; IJ, internal jugular; PA, pulmonary artery; TEE, transesophageal echocardiography. Prevention of central venous catheter sepsis: A prospective randomized trial. Level 3: The literature contains noncomparative observational studies with descriptive statistics (e.g., frequencies, percentages). Evolution and aetiological shift of catheter-related bloodstream infection in a whole institution: The microbiology department may act as a watchtower. Refer to appendix 5 for a summary of methods and analysis. Literature Findings. 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. Safety of central venous catheter change over guidewire for suspected catheter-related sepsis: A prospective randomized trial. Internal jugular vein cannulation: An ultrasound-guided technique. Comparison of triple-lumen central venous catheters impregnated with silver nanoparticles (AgTive). 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. Catheter-related infection and thrombosis of the internal jugular vein in hematologic-oncologic patients undergoing chemotherapy: A prospective comparison of silver-coated and uncoated catheters. Survey Findings. The policy of the American Society of Anesthesiologists (ASA) Committee on Standards and Practice Parameters is to update practice guidelines every 5 yr. Standardizing central line safety: Lessons learned for physician leaders. A delayed diagnosis of a retained guidewire during central venous catheterisation: A case report and review of the literature. Trendelenburg position does not increase cross-sectional area of the internal jugular vein predictably. 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. Insert the J-curved end of the guidewire into the introducer needle, with the J curve facing up. . 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. Fixed-effects models were fitted using MantelHaenszel or inverse variance weighting as appropriate. See 2017 Food and Drug Administration warning on chlorhexidine allergy. 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). When available, category A evidence is given precedence over category B evidence for any particular outcome. (Co-Chair), Wilmette, Illinois; Richard T. Connis, Ph.D. (Chief Methodologist), Woodinville, Washington; Karen B. Domino, M.D., M.P.H., Seattle, Washington; Mark D. Grant, M.D., Ph.D. (Senior Methodologist), Schaumburg, Illinois; and Jonathan B. This approach may not be feasible in emergency circumstances or in the presence of other clinical constraints. Reducing PICU central lineassociated bloodstream infections: 3-year results. Central venous cannulation: Are routine chest radiographs necessary after B-mode and colour Doppler sonography check? Time-series analysis to observe the impact of a centrally organized educational intervention on the prevention of central-lineassociated bloodstream infections in 32 German intensive care units. The long-term impact of a program to prevent central lineassociated bloodstream infections in a surgical intensive care unit. A multicenter intervention to prevent catheter-associated bloodstream infections. The rate of return was 17.4% (n = 19 of 109). Address correspondence to the American Society of Anesthesiologists: 1061 American Lane, Schaumburg, Illinois 60173. The needle was exchanged over the wire for an arterial . 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. Supplemental Digital Content is available for this article. The long-term effect of bundle care for catheter-related blood stream infection: 5-year follow-up. Findings were then summarized for each evidence linkage and reported in the text of the updated Guideline, with summary evidence tables available as Supplemental Digital Content 4 (http://links.lww.com/ALN/C9). Ultrasound-guided cannulation of the internal jugular vein: A prospective, randomized study. 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). Ultrasound guidance outcomes were pooled using risk or mean differences (continuous outcomes) for clinical relevance. The rapid atrial swirl sign for assessing central venous catheters: Performance by medical residents after limited training. 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. The consultants and ASA members both strongly agree with the recommendation to minimize the number of needle punctures of the skin. Central vascular catheter placement evaluation using saline flush and bedside echocardiography. Matching Michigan Collaboration & Writing Committee. Literature Findings. 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. Practice guidelines for central venous access: A report by the American Society of Anesthesiologists Task Force on Central Venous Access. 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. Improvement of internal jugular vein cannulation using an ultrasound-guided technique. tip should be at the cavoatrial junction. The insertion process includes catheter site selection, insertion under ultrasound guidance, catheter site dressing regimens, securement devices, and use of a CVC insertion bundle. Fatal brainstem stroke following internal jugular vein catheterization. Ultrasonography: A novel approach to central venous cannulation. Case reports describe severe injury (e.g., hemorrhage, hematoma, pseudoaneurysm, arteriovenous fistula, arterial dissection, neurologic injury including stroke, and severe or lethal airway obstruction) when unintentional arterial cannulation occurs with large-bore catheters (Category B4-H evidence).169178, An RCT comparing a thin-wall needle technique versus a catheter-over-the-needle for right internal jugular vein insertion in adults reports equivocal findings for first-attempt success rates and frequency of complications (Category A3-E evidence)179; for right-sided subclavian insertion in adults an RCT reports first-attempt success more likely and fewer complications with a thin-wall needle technique (Category A3-B evidence).180 One RCT reports equivocal findings for first-attempt success rates and frequency of complications when comparing a thin-wall needle with catheter-over-the-needle technique for internal jugular vein insertion (preferentially right) in neonates (Category A3-E evidence).181 Observational studies report a greater frequency of complications occurring with increasing number of insertion attempts (Category B3-H evidence).182184 One nonrandomized comparative study reports a higher frequency of dysrhythmia when two central venous catheters are placed in the same vein (right internal jugular) compared with placement of one catheter in the vein (Category B1-H evidence); differences in carotid artery punctures or hematomas were not noted (Category B1-E evidence).185. Prevention of central venous catheter-related infections by using maximal sterile barrier precautions during insertion. Evaluation and classification of evidence for the ASA clinical practice guidelines, Millers Anesthesia. Heterogeneity was quantified with I2 and prediction intervals estimated (see table 1). Order a chest x-ray to check for line position and pneumothorax if a jugular or subclavian line has . 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. Refer to appendix 3 for an example of a checklist or protocol. How useful is ultrasound guidance for internal jugular venous access in children? Prevention of catheter-related bloodstream infection in critically ill patients using a disinfectable, needle-free connector: A randomized controlled trial. This may be done in your hospital room or an . Does ultrasound imaging before puncture facilitate internal jugular vein cannulation? Literature Findings. document the position of the line. Aiming for zero: Decreasing central line associated bacteraemia in the intensive care unit. 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. Single-operator ultrasound-guided central venous catheter insertion verifies proper tip placement. These suggestions include, but are not limited to, positioning the patient in the Trendelenburg position, using the Valsalva maneuver, applying direct pressure to the puncture site, using air-occlusive dressings, and monitoring the patient for a reasonable period of time after catheter removal. Retention of the antibiotic teicoplanin on a hydromer-coated central venous catheter to prevent bacterial colonization in postoperative surgical patients. Central Line Insertion Care Team Checklist. There are many uses of these catheters. Eliminating catheter-related bloodstream infections in the intensive care unit. An intervention to decrease catheter-related bloodstream infections in the ICU. 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. 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. 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. Central venous line placement is typically performed at four sites in the body: . The consultants and ASA members strongly agree that when unintended cannulation of an arterial vessel with a dilator or large-bore catheter occurs, leave the dilator or catheter in place and immediately consult a general surgeon, a vascular surgeon, or an interventional radiologist regarding surgical or nonsurgical catheter removal for adults. 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). Ultrasound validation of maneuvers to increase internal jugular vein cross-sectional area and decrease compressibility. 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. Studies also report high specificities of transthoracic ultrasound for excluding the presence of a pneumothorax.216,218,219,227229,232,233,236,238,240. Level 2: The literature contains noncomparative observational studies with associative statistics (e.g., correlation, sensitivity, and specificity). The subclavian veins are an often favored site for central venous access, including emergency and acute care access, and tunneled catheters and subcutaneous ports for chemotherapy, prolonged antimicrobial therapy, and parenteral . 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. Refer to appendix 2 for an example of a list of standardized equipment for adult patients. Reducing the rate of catheter-associated bloodstream infections in a surgical intensive care unit using the Institute for Healthcare Improvement Central Line Bundle. Survey Findings. Using the comprehensive unit-based safety program model for sustained reduction in hospital infections. Posterior cerebral infarction following loss of guide wire. Received from the American Society of Anesthesiologists, Schaumburg, Illinois. Chlorhexidine-impregnated sponges and less frequent dressing changes for prevention of catheter-related infections in critically ill adults: A randomized controlled trial. A subclavian artery injury, secondary to internal jugular vein cannulation, is a predictable right-sided phenomenon. Literature Findings. Effectiveness of a programme to reduce the burden of catheter-related bloodstream infections in a tertiary hospital. 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. Literature Findings. Decreasing central-lineassociated bloodstream infections in Connecticut intensive care units. Eradicating central lineassociated bloodstream infections statewide: The Hawaii experience.