Iatrogenic injury of vertebral artery resulting in stroke after central venous line insertion. Practice Guidelines for Central Venous Access 2020: An Updated Report by the American Society of Anesthesiologists Task Force on Central Venous Access. Safety of central venous catheter change over guidewire for suspected catheter-related sepsis: A prospective randomized trial. Ultrasound guidance outcomes were pooled using risk or mean differences (continuous outcomes) for clinical relevance. A multidisciplinary approach to reduce central lineassociated bloodstream infections. document the position of the line. Reduction of catheter-related infections in neutropenic patients: A prospective controlled randomized trial using a chlorhexidine and silver sulfadiazine-impregnated central venous catheter. Determine catheter insertion site selection based on clinical need and practitioner judgment, experience, and skill, Select an upper body insertion site when possible to minimize the risk of thrombotic complications relative to the femoral site, Perform central venous access in the neck or chest with the patient in the Trendelenburg position when clinically appropriate and feasible, Select catheter size (i.e., outside diameter) and type based on the clinical situation and skill/experience of the operator, Select the smallest size catheter appropriate for the clinical situation, For the subclavian approach select a thin-wall needle (i.e., Seldinger) technique versus a catheter-over-the-needle (i.e., modified Seldinger) technique, For the jugular or femoral approach, select a thin-wall needle or catheter-over-the-needle technique based on the clinical situation and the skill/experience of the operator, For accessing the vein before threading a dilator or large-bore catheter, 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 (fig. Misplacement of a guidewire diagnosed by transesophageal echocardiography. Complications and failures of subclavian-vein catheterization. Remove the dilator and pass the central line over the Seldinger wire. Preparation of these updated guidelines followed a rigorous methodological process. 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. Comparison of central venous catheterization with and without ultrasound guide. Objective To investigate the efficacy of the minimally invasive clamp reduction technique via the anterior approach in the treatment of irreducible intertrochanteric femoral fractures. Catheter infection: A comparison of two catheter maintenance techniques. Central venous catheters coated with minocycline and rifampin for the prevention of catheter-related colonization and bloodstream infections: A randomized, double-blind trial. A retrospective observational study reports that manometry can detect arterial punctures not identified by blood flow and color (Category B3-B evidence).213 The literature is insufficient to address ultrasound, pressure-waveform analysis, blood gas analysis, blood color, or the absence of pulsatile flow as effective methods of confirming catheter or thin-wall needle venous access. 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. A minimum of five independent RCTs (i.e., sufficient for fitting a random-effects model255) is required for meta-analysis. Catheter-associated bloodstream infection in the pediatric intensive care unit: A multidisciplinary approach. Ideally the distal end of a CVC should be orientated vertically within the SVC. - right femoral line: find the arterial pulse and enter the skin 1 cm medial to this, at a 45 angle to the vertical and heading parallel to the artery. It can be used to confirm that the catheter or the guidewire has travelled towards the SVC. Decreasing central lineassociated bloodstream infections through quality improvement initiative. 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. A controlled study of transesophageal echocardiography to guide central venous catheter placement in congenital heart surgery patients. 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. Anaphylaxis to chlorhexidine in a chlorhexidine-coated central venous catheter during general anaesthesia. New York State Regional Perinatal Care Centers. tip should be at the cavoatrial junction. CLABSI Toolkit - Chapter 3 | The Joint Commission Chlorhexidine and silver-sulfadiazine coated central venous catheters in haematological patients: A double-blind, randomised, prospective, controlled trial. When an equal number of categorically distinct responses are obtained, the median value is determined by calculating the arithmetic mean of the two middle values. 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). Two episodes of life-threatening anaphylaxis in the same patient to a chlorhexidine-sulphadiazine-coated central venous catheter. The accuracy of electrocardiogram-controlled central line placement. 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). Meta: An R package for meta-analysis (4.9-4). The journey to zero central catheter-associated bloodstream infections: Culture change in an intensive care unit. hemorrhage, hematoma formation, and pneumothorax during central line placement. The consultants and ASA members strongly agree with the recommendation to perform central venous catheterization in an environment that permits use of aseptic techniques and to ensure that a standardized equipment set is available for central venous access. Reducing the rate of catheter-associated bloodstream infections in a surgical intensive care unit using the Institute for Healthcare Improvement Central Line Bundle. Do not force the wire; it should slide smoothly. For neonates, the consultants and ASA members agree with the recommendation to determine the use of transparent or sponge dressings containing chlorhexidine based on clinical judgment and institutional protocol. 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. 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. 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. 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. 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). Iatrogenic arteriovenous fistula: A complication of percutaneous subclavian vein puncture. 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. Three-rater values between two methodologists and task force reviewers were: (1) research design, = 0.70; (2) type of analysis, = 0.68; (3) linkage assignment, = 0.79; and (4) literature database inclusion, = 0.65. For these updated guidelines, a systematic search and review of peer-reviewed published literature was conducted, with scientific findings summarized and reported below and in the document. Do not force the wire; it should slide smoothly. Next, place the larger (20- to 22-gauge) needle immediately. Anesthesia was achieved using 1% lidocaine. I have read and accept the terms and conditions. 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. Insert the J-curved end of the guidewire into the introducer needle, with the J curve facing up. 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. 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. 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 A significance level of P < 0.01 was applied for analyses. Random-effects models were fitted with inverse variance weighting using the DerSimonian and Laird estimate of between-study variance. PDF Central Line Insertion Checklist - Template - Joint Commission Refer to appendix 3 for an example of a checklist or protocol. 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. Randomized controlled trial of chlorhexidine dressing and highly adhesive dressing for preventing catheter-related infections in critically ill adults. 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.