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. RCTs report equivocal findings for catheter tip colonization when catheters are changed at 3-day versus 7-day intervals (Category A2-E evidence).146,147 RCTs report equivocal findings for catheter tip colonization when guidewires are used to change catheters compared with new insertion sites (Category A2-E evidence).148150. I have read and accept the terms and conditions. (Committee Chair), Chicago, Illinois; Stephen M. Rupp, M.D. Guidewire catheter change in central venous catheter biofilm formation in a burn population. A randomized, prospective clinical trial to assess the potential infection risk associated with the PosiFlow needleless connector. NICE guidelines for central venous catheterization in children: Is the evidence base sufficient? Level 4: The literature contains case reports. Power analysis for random-effects meta-analysis. 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. Anaphylaxis to chlorhexidine in a chlorhexidine-coated central venous catheter during general anaesthesia. Prepare the centralcatheter kit, and A complete bibliography used to develop this updated Advisory, arranged alphabetically by author, is available as Supplemental Digital Content 1, http://links.lww.com/ALN/C6. . The impact of a quality improvement intervention to reduce nosocomial infections in a PICU. 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. Subclavian venous catheterization: Greater success rate for less experienced operators using ultrasound guidance. Advance the wire 20 to 30 cm. 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. Decreasing central-lineassociated bloodstream infections in Connecticut intensive care units. Ultrasound-guided internal jugular venous cannulation in infants: A prospective comparison with the traditional palpation method. 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. Ultrasound localization of central vein catheter and detection of postprocedural pneumothorax: An alternative to chest radiography. A minimum of five independent RCTs (i.e., sufficient for fitting a random-effects model255) is required for meta-analysis. Ultrasound confirmation of guidewire position may eliminate accidental arterial dilatation during central venous cannulation. Literature Findings. 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. Comparison of the efficacy of three topical antiseptic solutions for the prevention of catheter colonization: A multicenter randomized controlled study. Survey 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. Reduction of catheter-related bloodstream infections through the use of a central venous line bundle: Epidemiologic and economic consequences. Literature Findings. Sensitivity to effect measure was also examined. Reduction and surveillance of device-associated infections in adult intensive care units at a Saudi Arabian hospital, 20042011. Only studies containing original findings from peer-reviewed journals were acceptable. 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. 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. The journey to zero central catheter-associated bloodstream infections: Culture change in an intensive care unit. Submitted for publication March 15, 2019. Choice of route for central venous cannulation: Subclavian or internal jugular vein? A chest x-ray will be performed immediately following thoracic central line placement to assure line placement and rule out pneumothorax. Risk factors for catheter-related bloodstream infection: A prospective multicenter study in Brazilian intensive care units. Missed carotid artery cannulation: A line crossed and lessons learnt. Cerebral infarct following central venous cannulation. A prospective randomized study to compare ultrasound-guided with nonultrasound-guided double lumen internal jugular catheter insertion as a temporary hemodialysis access. 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. The consultants and ASA members strongly agree with the recommendation to determine catheter insertion site selection based on clinical need and practitioner judgment, experience, and skill. Zero risk for central lineassociated bloodstream infection: Are we there yet? The average age of the patients was 78.7 (45-100 years old . RCTs comparing subclavian and femoral insertion sites report higher rates of catheter colonization at the femoral site (Category A2-H evidence); findings for catheter-related sepsis or catheter-related bloodstream infection are equivocal (Category A2-E evidence).130,131 An RCT finds a higher rate of catheter colonization for internal jugular compared with subclavian insertion (Category A3-H evidence) and for femoral compared with internal jugular insertion (Category A3-H evidence); evidence is equivocal for catheter-related bloodstream infection for either comparison (Category A3-E evidence).131 A nonrandomized comparative study of burn patients reports that catheter colonization and catheter-related bloodstream infection occur more frequently with an insertion site closer to the burn location (Category B1-H evidence).132. Literature Findings. This may be done in your hospital room or an . 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). A literature search strategy and PRISMA* flow diagram are available as Supplemental Digital Content 2 (http://links.lww.com/ALN/C7). Use of electronic medical recordenhanced checklist and electronic dashboard to decrease CLABSIs. Meta: An R package for meta-analysis (4.9-4). Received from the American Society of Anesthesiologists, Schaumburg, Illinois. Standardizing central line safety: Lessons learned for physician leaders. Catheter infection risk related to the distance between insertion site and burned area. These large diameter central veins are located universally near a large artery. Pooled estimates from RCTs are consistent with lower rates of catheter colonization with chlorhexidine sponge dressings compared with standard polyurethane (Category A1-B evidence)90,133138 but equivocal for catheter-related bloodstream infection (Category A1-E evidence).90,133140 An RCT reports a higher frequency of severe localized contact dermatitis in neonates with chlorhexidine-impregnated dressings compared with povidoneiodineimpregnated dressings (Category A3-H evidence)133; findings concerning dermatitis from RCTs in adults are equivocal (Category A2-E evidence).90,134,136,137,141. Remove the dilator and pass the central line over the Seldinger wire. 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. The consultants and ASA members agree with the recommendation to use catheters coated with antibiotics or a combination of chlorhexidine and silver sulfadiazine based on infectious risk and anticipated duration of catheter use for selected patients. window the image to best visualize the line. Saline flush test: Can bedside sonography replace conventional radiography for confirmation of above-the-diaphragm central venous catheter placement? Impact of two bundles on central catheter-related bloodstream infection in critically ill patients. Mark, M.D., Durham, North Carolina. Use real-time ultrasound guidance for vessel localization and venipuncture when the internal jugular vein is selected for cannulation (see fig. Retention of the antibiotic teicoplanin on a hydromer-coated central venous catheter to prevent bacterial colonization in postoperative surgical patients. Identical surveys were distributed to expert consultants and a random sample of members of the participating organizations. 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. This line is placed into a large vein in the neck. 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 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.) The epidemiology, antibiograms and predictors of mortality among critically-ill patients with central lineassociated bloodstream infections. Direct URL citations appear in the printed text and are available in both the HTML and PDF versions of this article. 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. Prepare the skin with chlorhexidine, and cover the area with a sterile drape. An alternative central venous route for cardiac surgery: Supraclavicular subclavian vein catheterization. Incidence of mechanical complications of central venous catheterization using landmark technique: Do not try more than 3 times. Efficacy of silver-coating central venous catheters in reducing bacterial colonization. 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 . tip too high: proximal SVC. Arterial trauma during central venous catheter insertion: Case series, review and proposed algorithm. The consultants and ASA members agree that needleless catheter access ports may be used on a case-by-case basis, Do not routinely administer intravenous antibiotic prophylaxis, In preparation for the placement of central venous catheters, use aseptic techniques (e.g., hand washing) and maximal barrier precautions (e.g., sterile gowns, sterile gloves, caps, masks covering both mouth and nose, full-body patient drapes, and eye protection), Use a chlorhexidine-containing solution for skin preparation in adults, infants, and children, For neonates, determine the use of chlorhexidine-containing solutions for skin preparation based on clinical judgment and institutional protocol, If there is a contraindication to chlorhexidine, povidoneiodine or alcohol may be used, Unless contraindicated, use skin preparation solutions containing alcohol, For selected patients, use catheters coated with antibiotics, a combination of chlorhexidine and silver sulfadiazine, or silver-platinum-carbonimpregnated catheters based on risk of infection and anticipated duration of catheter use, Do not use catheters containing antimicrobial agents as a substitute for additional infection precautions, Determine catheter insertion site selection based on clinical need, 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), In adults, select an upper body insertion site when possible to minimize the risk of infection, Determine the use of sutures, staples, or tape for catheter fixation on a local or institutional basis, Minimize the number of needle punctures of the skin, Use transparent bioocclusive dressings to protect the site of central venous catheter insertion from infection, Unless contraindicated, dressings containing chlorhexidine may be used in adults, infants, and children, For neonates, determine the use of transparent or sponge dressings containing chlorhexidine based on clinical judgment and institutional protocol, If a chlorhexidine-containing dressing is used, observe the site daily for signs of irritation, allergy, or necrosis, Determine the duration of catheterization based on clinical need, Assess the clinical need for keeping the catheter in place on a daily basis, Remove catheters promptly when no longer deemed clinically necessary, Inspect the catheter insertion site daily for signs of infection, Change or remove the catheter when catheter insertion site infection is suspected, When a catheter-related infection is suspected, a new insertion site may be used for catheter replacement rather than changing the catheter over a guidewire, Clean catheter access ports with an appropriate antiseptic (e.g., alcohol) before each access when using an existing central venous catheter for injection or aspiration, Cap central venous catheter stopcocks or access ports when not in use, Needleless catheter access ports may be used on a case-by-case basis. Chlorhexidine-impregnated dressings and prevention of catheter-associated bloodstream infections in a pediatric intensive care unit. 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.