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. 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 . Inadvertent prolonged cannulation of the carotid artery. After review, 729 were excluded, with 284 new studies meeting inclusion criteria. Meta-analyses from other sources are reviewed but not included as evidence in this document. Decreasing central lineassociated bloodstream infections through quality improvement initiative. ), Tunneled catheters (e.g., Hickman, Quinton, permacaths, portacaths), Arterial cannulation/injury/cerebral embolization/hemorrhage, Wire, knot, inability to remove the catheter, Hospital, intensive care unit length of stay, Number of attempts at central line placement, Time required for placement of central venous catheters, Infections or other complications not associated with central venous catheterization, Mechanical injury or trauma not associated with central venous catheterization, Prospective nonrandomized comparative studies (e.g., quasiexperimental, cohort), Retrospective comparative studies (e.g., case-control), Observational studies (e.g., correlational or descriptive statistics). Beyond the bundle: Journey of a tertiary care medical intensive care unit to zero central lineassociated bloodstream infections. Supplemental Digital Content is available for this article. The vessel traverses the thigh and takes a superficial course at the femoral triangle before passing beneath the inguinal ligament into the pelvis as the external iliac vein (figure 1A-B). First, consensus was reached on the criteria for evidence. Arterial misplacement of large-caliber cannulas during jugular vein catheterization: Case for surgical management. Central venous access above the diaphragm, unless contraindicated, is generally preferred to femoral venous access in patients who require central venous access. Chlorhexidine-impregnated dressing for prevention of colonization of central venous catheters in infants and children: A randomized controlled study. Where Should the Femoral Central Line Be Placed? Impact of two bundles on central catheter-related bloodstream infection in critically ill patients. NICE guidelines for central venous catheterization in children: Is the evidence base sufficient? Is a routine chest x-ray necessary for children after fluoroscopically assisted central venous access? 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. = 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%. Impact of a national multimodal intervention to prevent catheter-related bloodstream infection in the ICU: The Spanish experience. Benefits of minocycline and rifampin-impregnated central venous catheters: A prospective, randomized, double-blind, controlled, multicenter trial. - 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. Antiseptic-bonded central venous catheters and bacterial colonisation. Skin antisepsis with chlorhexidinealcohol, for Japanese Society of Education for Physicians and Trainees in Intensive Care (JSEPTIC) Clinical Trial Group. A total of 3 supervised re-wires is required prior to performing a rewire . Prospective randomised trial of povidoneiodine, alcohol, and chlorhexidine for prevention of infection associated with central venous and arterial catheters. Sterility In the ED, there are only two ways to place central lines: Full Sterile or Non-Sterile There is no in-between. 1), The number of insertion attempts should be based on clinical judgment, The decision to place two catheters in a single vein should be made on a case-by-case basis. Use the subclavian site for central lines: Compared to the internal jugular or femoral sites, the subclavian site has a lower risk of thrombosis or line infection. Survey Findings. . From ICU to hospital-wide: Extending central line associated bacteraemia (CLAB) prevention. A multicentre analysis of catheter-related infection based on a hierarchical model. Comparison of alcoholic chlorhexidine and povidoneiodine cutaneous antiseptics for the prevention of central venous catheter-related infection: A cohort and quasi-experimental multicenter study. Survey Findings. Catheter-Related Infections in ICU (CRI-ICU) Group. Implementation of central lineassociated bloodstream infection prevention bundles in a surgical intensive care unit using peer tutoring. 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. Trendelenburg position does not increase cross-sectional area of the internal jugular vein predictably. 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. Editorials, letters, and other articles without data were excluded. The insertion process includes catheter site selection, insertion under ultrasound guidance, catheter site dressing regimens, securement devices, and use of a CVC insertion bundle. 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. For studies that report statistical findings, the threshold for significance is P < 0.01. How To Do Femoral Vein Cannulation - Critical Care Medicine - Merck Central venous line sepsis in the intensive care unit: A study comparing antibiotic coated catheters with plain catheters. Refer to appendix 2 for an example of a list of standardized equipment for adult patients. Refer to appendix 4 for an example of a list of duties performed by an assistant. Ultrasound guidance improves the success rate of internal jugular vein cannulation: A prospective, randomized trial. 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. Internal jugular vein cannulation: An ultrasound-guided technique. Aseptic techniques using an existing central venous catheter for injection or aspiration consist of (1) wiping the port with an appropriate antiseptic, (2) capping stopcocks or access ports, and (3) use of needleless catheter connectors or access ports. Each pertinent outcome reported in a study was classified by evidence category and level and designated as beneficial, harmful, or equivocal. 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. For neonates, infants, and children, confirmation of venous placement may take place after the wire is threaded. Single-operator ultrasound-guided central venous catheter insertion verifies proper tip placement. Internal jugular line. 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. What Is A Central Venous Catheter? - Cleveland Clinic Efficacy of antiseptic-impregnated catheters on catheter colonization and catheter-related bloodstream infections in patients in an intensive care unit. Your groin area is cleaned and shaved. 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. Usefulness of ultrasonography for the evaluation of catheter misplacement and complications after central venous catheterization. An alternative central venous route for cardiac surgery: Supraclavicular subclavian vein catheterization. The rapid atrial swirl sign for assessing central venous catheters: Performance by medical residents after limited training. Target CLAB Zero: A national improvement collaborative to reduce central lineassociated bacteraemia in New Zealand intensive care units. 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). Venous blood gases must be obtained at the time of central line insertion or upon admission of a patient with an established central line (including femoral venous lines) and as an endpoint to resuscitation or . The utility of transthoracic echocardiography to confirm central line placement: An observational study. Reduction of central line infections in Veterans Administration intensive care units: An observational cohort using a central infrastructure to support learning and improvement. Comparison of silver-impregnated with standard multi-lumen central venous catheters in critically ill patients. Effectiveness of stepwise interventions targeted to decrease central catheter-associated bloodstream infections. Reducing central lineassociated bloodstream infections in three ICUs at a tertiary care hospital in the United Arab Emirates. Survey Findings. Netcare Antimicrobial Stewardship and Infection Prevention Study Alliance. The venous great vessels include the superior vena cava, inferior vena cava, brachiocephalic veins, internal jugular veins, subclavian veins, iliac veins, and common femoral veins. Excluded are catheters that terminate in a systemic artery. Chlorhexidine and silver-sulfadiazine coated central venous catheters in haematological patients: A double-blind, randomised, prospective, controlled trial. Hospital-wide multidisciplinary, multimodal intervention programme to reduce central venous catheter-associated bloodstream infection. Reduced intravascular catheter infection by antibiotic bonding: A prospective, randomized, controlled trial. Strict hand hygiene and other practices shortened stays and cut costs and mortality in a pediatric intensive care unit. 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 literature relating to seven evidence linkages contained enough studies with well defined experimental designs and statistical information to conduct formal meta-analyses (table 1). Ultrasound identification of the guidewire in the brachiocephalic vein for the prevention of inadvertent arterial catheterization during internal jugular central venous catheter placement. Prepare the skin with chlorhexidine, and cover the area with a sterile drape. Use of electronic medical recordenhanced checklist and electronic dashboard to decrease CLABSIs. Methods for confirming that the catheter is still in the venous system after catheterization and before use include manometry, pressure-waveform measurement, or contrast-enhanced ultrasound. 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. Remove the dilator and pass the central line over the Seldinger wire. The SiteRite ultrasound machine: An aid to internal jugular vein cannulation. These studies do not permit assessing the effect of any single component of a checklist or bundled protocol on infection rates. Literature Findings. A multidisciplinary approach to reduce central lineassociated bloodstream infections. Comparison of needle insertion and guidewire placement techniques during internal jugular vein catheterization: The thin-wall introducer needle technique. 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. Influence of triple-lumen central venous catheters coated with chlorhexidine and silver sulfadiazine on the incidence of catheter-related bacteremia. No search for gray literature was conducted. Central Venous Line Placement - University of Florida Meta-analyses of RCTs comparing real-time ultrasound-guided venipuncture of the internal jugular with an anatomical landmark approach report higher first insertion attempt success rates,186197 higher overall success rates,186,187,189192,194204 lower rates of arterial puncture,186188,190201,203,205 and fewer insertion attempts (Category A1-B evidence).188,190,191,194197,199,200,203205 RCTs also indicate reduced access time or times to cannulation with ultrasound compared with a landmark approach (Category A2-B evidence).188,191,194196,199,200,202205, For the subclavian vein, RCTs report fewer insertion attempts with real-time ultrasound-guided venipuncture (Category A2-B evidence),206,207 and higher overall success rates (Category A2-B evidence).206208 When compared with a landmark approach, findings are equivocal for arterial puncture207,208 and hematoma (Category A2-E evidence).207,208 For the femoral vein, an RCT reports a higher first-attempt success rate and fewer needle passes with real-time ultrasound-guided venipuncture compared with the landmark approach in pediatric patients (Category A3-B evidence).209, Meta-analyses of RCTs comparing static ultrasound with a landmark approach yields equivocal evidence for improved overall success for internal jugular insertion (Category A1-E evidence),190,202,210212 overall success irrespective of insertion site (Category A1-E evidence),182,190,202,210212 or impact on arterial puncture rates (Category A1-E evidence).190,202,210212 RCTs comparing static ultrasound with a landmark approach for locating the internal jugular vein report a higher first insertion attempt success rate with static ultrasound (Category A3-B evidence).190,212 The literature is equivocal regarding overall success for subclavian vein access (Category A3-E evidence)182 or femoral vein access when comparing static ultrasound to the landmark approach (Category A3-E evidence).202.
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