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Practice Guidelines for Central Venous AccessA Report by the American Society of Anesthesiologists TaskForce on Central Ve...
Practice GuidelinesHickman®, Quinton®, (6) methods of detection or treat-                         Scientific Evidencement ...
SPECIAL ARTICLESCategory D: Insufficient Evidence from Literature                             Disagree. Median score of 2 ...
Practice GuidelinesII. Prevention of Infectious Complications                                100%), caps (100% and 94.7%),...
SPECIAL ARTICLEScomparing silver-impregnated catheters with uncoated cath-                Recommendations for Selection of...
Practice GuidelinesCatheter Maintenance. Catheter maintenance consists of (1)                 connectors with standard cap...
SPECIAL ARTICLESskill. In adults, selection of an upper body insertion site                  tion, and the skill and exper...
Practice GuidelinesFig. 1. Algorithm for central venous insertion and verification. This algorithm compares the thin-wall ...
SPECIAL ARTICLESrates of arterial puncture (Category A1 evidence).                         identifying the position of the...
Practice Guidelines    should not be relied upon for confirming that the catheter             nonsurgically, as follows: 5...
SPECIAL ARTICLES  ⅙ If there is a contraindication to chlorhexidine, povidone-io-                ⅙ In adults, selection of...
Practice Guidelines  firmation of venous location of the catheter, and (2) when the                 Appendix 2. Example of...
SPECIAL ARTICLESAppendix 3. Example of a Central Venous Catheterization Checklist    Central Line Insertion Standard Work ...
Practice GuidelinesAppendix 3. Continued             10. Ultrasound Guidance Used for Elective Internal Jugular insertions...
SPECIAL ARTICLESAppendix 4. Example Duties Performed by an                                      Silver-impregnated cathete...
Practice guidelines for_central_venous_access__a.13
Practice guidelines for_central_venous_access__a.13
Practice guidelines for_central_venous_access__a.13
Practice guidelines for_central_venous_access__a.13
Practice guidelines for_central_venous_access__a.13
Practice guidelines for_central_venous_access__a.13
Practice guidelines for_central_venous_access__a.13
Practice guidelines for_central_venous_access__a.13
Practice guidelines for_central_venous_access__a.13
Practice guidelines for_central_venous_access__a.13
Practice guidelines for_central_venous_access__a.13
Practice guidelines for_central_venous_access__a.13
Practice guidelines for_central_venous_access__a.13
Practice guidelines for_central_venous_access__a.13
Practice guidelines for_central_venous_access__a.13
Practice guidelines for_central_venous_access__a.13
Practice guidelines for_central_venous_access__a.13
Practice guidelines for_central_venous_access__a.13
Practice guidelines for_central_venous_access__a.13
Practice guidelines for_central_venous_access__a.13
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Practice guidelines for_central_venous_access__a.13

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Practice guidelines for_central_venous_access__a.13

  1. 1. Practice Guidelines for Central Venous AccessA Report by the American Society of Anesthesiologists TaskForce on Central Venous AccessP RACTICE Guidelines are systematically developed rec- ommendations that assist the practitioner and patientin making decisions about health care. These recommenda- • What other guideline statements are available on this topic? X Several major organizations have produced practice guide- lines on central venous access128 –132tions may be adopted, modified, or rejected according to • Why was this Guideline developed?clinical needs and constraints, and are not intended to re- X The ASA has created this new Practice Guideline to provideplace local institutional policies. In addition, Practice Guide- updated recommendations on some issues and new rec- ommendations on issues that have not been previously ad-lines developed by the American Society of Anesthesiologists dressed by other guidelines. This was based on a rigorous(ASA) are not intended as standards or absolute require- evaluation of recent scientific literature as well as findingsments, and their use cannot guarantee any specific outcome. from surveys of expert consultants and randomly selectedPractice Guidelines are subject to revision as warranted by ASA membersthe evolution of medical knowledge, technology, and prac- • How does this statement differ from existing guidelines? X The ASA Guidelines differ in areas such as insertion sitetice. They provide basic recommendations that are sup- selection (e.g., upper body site) guidance for catheter place-ported by a synthesis and analysis of the current literature, ment (e.g., use of real-time ultrasound) and verification ofexpert and practitioner opinion, open forum commentary, venous location of the catheterand clinical feasibility data. • Why does this statement differ from existing guidelines? X The ASA Guidelines differ from existing guidelines because it addresses the use of bundled techniques, use of an as-Methodology sistant during catheter placement, and management of ar- terial injuryA. Definition of Central Venous AccessFor these Guidelines, central venous access is defined asplacement of a catheter such that the catheter is inserted into internal jugular veins, subclavian veins, iliac veins, and com-a venous great vessel. The venous great vessels include the mon femoral veins.* Excluded are catheters that terminate insuperior vena cava, inferior vena cava, brachiocephalic veins, a systemic artery. Developed by the American Society of Anesthesiologists Task B. Purposes of the GuidelinesForce on Central Venous Access: Stephen M. Rupp, M.D., Seattle, The purposes of these Guidelines are to (1) provide guid-Washington (Chair); Jeffrey L. Apfelbaum, M.D., Chicago, Illinois;Casey Blitt, M.D., Tucson, Arizona; Robert A. Caplan, M.D., Seattle, ance regarding placement and management of central ve-Washington; Richard T. Connis, Ph.D., Woodinville, Washington; nous catheters, (2) reduce infectious, mechanical, throm-Karen B. Domino, M.D., M.P.H., Seattle, Washington; Lee A. Fleisher, botic, and other adverse outcomes associated with centralM.D., Philadelphia, Pennsylvania; Stuart Grant, M.D., Durham, NorthCarolina; Jonathan B. Mark, M.D., Durham, North Carolina; Jeffrey P. venous catheterization, and (3) improve management ofMorray, M.D., Paradise Valley, Arizona; David G. Nickinovich, Ph.D., arterial trauma or injury arising from central venous cath-Bellevue, Washington; and Avery Tung, M.D., Wilmette, Illinois. eterization. Received from the American Society of Anesthesiologists, ParkRidge, Illinois. Submitted for publication October 20, 2011. Acceptedfor publication October 20, 2011. Supported by the American Society of C. FocusAnesthesiologists and developed under the direction of the Committee These Guidelines apply to patients undergoing elective cen-on Standards and Practice Parameters, Jeffrey L. Apfelbaum, M.D. tral venous access procedures performed by anesthesiologists(Chair). Approved by the ASA House of Delegates on October 19,2011. Endorsed by the Society of Cardiovascular Anesthesiologists, or health care professionals under the direction/supervisionOctober 4, 2010; the Society of Critical Care Anesthesiologists March 16, of anesthesiologists. The Guidelines do not address (1) clin-2011; the Society of Pediatric Anesthesia March 29, 2011. A complete ical indications for placement of central venous catheters, (2)list of references used to develop these updated Guidelines, arrangedalphabetically by author, is available as Supplemental Digital Content 1, emergency placement of central venous catheters, (3) pa-http://links.lww.com/ALN/A783. tients with peripherally inserted central catheters, (4) place- Address correspondence to the American Society of Anesthesi- ment and residence of a pulmonary artery catheter, (5) inser-ologists: 520 North Northwest Highway, Park Ridge, Illinois 60068- tion of tunneled central lines (e.g., permacaths, portacaths,2573. These Practice Guidelines, as well as all ASA Practice Param-eters, may be obtained at no cost through the Journal Web site,www.anesthesiology.org. Supplemental digital content is available for this article. Direct * This description of the venous great vessels is consistent with URL citations appear in the printed text and are available inthe venous subset for central lines defined by the National Health- both the HTML and PDF versions of this article. Links to thecare Safety Network (NHSN). digital files are provided in the HTML text of this article on theCopyright © 2012, the American Society of Anesthesiologists, Inc. Lippincott Journal’s Web site (www.anesthesiology.org).Williams & Wilkins. Anesthesiology 2012; 116:539 –73Anesthesiology, V 116 • No 3 539 March 2012
  2. 2. Practice GuidelinesHickman®, Quinton®, (6) methods of detection or treat- Scientific Evidencement of infectious complications associated with central ve- Study findings from published scientific literature were ag-nous catheterization, or (7) diagnosis and management of gregated and are reported in summary form by evidence cat-central venous catheter-associated trauma or injury (e.g., egory, as described in the following paragraphs. All literaturepneumothorax or air embolism), with the exception of ca- (e.g., randomized controlled trials, observational studies, caserotid arterial injury. reports) relevant to each topic was considered when evaluat- ing the findings. However, for reporting purposes in thisD. Application document, only the highest level of evidence (i.e., level 1, 2,These Guidelines are intended for use by anesthesiologists or 3 within category A, B, or C, as identified in the followingand individuals who are under the supervision of an anes- paragraphs) is included in the summary.thesiologist. They also may serve as a resource for otherphysicians (e.g., surgeons, radiologists), nurses, or health Category A: Supportive Literaturecare providers who manage patients with central venous Randomized controlled trials report statistically significantcatheters. (P Ͻ 0.01) differences between clinical interventions for a specified clinical outcome.E. Task Force Members and Consultants Level 1: The literature contains multiple randomized con-The ASA appointed a Task Force of 12 members, including trolled trials, and aggregated findings are supportedanesthesiologists in both private and academic practice from by meta-analysis.‡various geographic areas of the United States and two con- Level 2: The literature contains multiple randomized con-sulting methodologists from the ASA Committee on Stan- trolled trials, but the number of studies is insuffi-dards and Practice Parameters. cient to conduct a viable meta-analysis for the pur- The Task Force developed the Guidelines by means of a pose of these Guidelines.seven-step process. First, they reached consensus on the cri- Level 3: The literature contains a single randomized con-teria for evidence. Second, original published research stud- trolled trial.ies from peer-reviewed journals relevant to central venousaccess were reviewed and evaluated. Third, expert consul- Category B: Suggestive Literaturetants were asked to (1) participate in opinion surveys on the Information from observational studies permits inference ofeffectiveness of various central venous access recommenda- beneficial or harmful relationships among clinical interven-tions and (2) review and comment on a draft of the Guide- tions and clinical outcomes.lines. Fourth, opinions about the Guideline recommenda- Level 1: The literature contains observational comparisonstions were solicited from a sample of active members of the (e.g., cohort, case-control research designs) of clin-ASA. Opinions on selected topics related to pediatric pa- ical interventions or conditions and indicates statis-tients were solicited from a sample of active members of the tically significant differences between clinical inter-Society for Pediatric Anesthesia (SPA). Fifth, the Task Force ventions for a specified clinical outcome.held open forums at three major national meetings† to solicit Level 2: The literature contains noncomparative observa-input on its draft recommendations. Sixth, the consultants tional studies with associative (e.g., relative risk,were surveyed to assess their opinions on the feasibility of correlation) or descriptive statistics.implementing the Guidelines. Seventh, all available informa- Level 3: The literature contains case reports.tion was used to build consensus within the Task Force tofinalize the Guidelines. A summary of recommendations Category C: Equivocal Literaturemay be found in appendix 1. The literature cannot determine whether there are beneficial or harmful relationships among clinical interventions andF. Availability and Strength of Evidence clinical outcomes.Preparation of these Guidelines followed a rigorous meth- Level 1: Meta-analysis did not find significant differencesodologic process. Evidence was obtained from two principal (P Ͼ 0.01) among groups or conditions.sources: scientific evidence and opinion-based evidence. Level 2: The number of studies is insufficient to conduct meta-analysis, and (1) randomized controlled trials † Society for Pediatric Anesthesia Winter Meeting, April 17, 2010,San Antonio, Texas; Society of Cardiovascular Anesthesia 32nd have not found significant differences amongAnnual Meeting, April 25, 2010, New Orleans, Louisiana, and Inter- groups or conditions or (2) randomized controllednational Anesthesia Research Society Annual Meeting, May 22, 2011, trials report inconsistent findings.Vancouver, British Columbia, Canada. Level 3: Observational studies report inconsistent findings ‡ All meta-analyses are conducted by the ASA methodologygroup. Meta-analyses from other sources are reviewed but not or do not permit inference of beneficial or harmfulincluded as evidence in this document. relationships.Anesthesiology 2012; 116:539 –73 540 Practice Guidelines
  3. 3. SPECIAL ARTICLESCategory D: Insufficient Evidence from Literature Disagree. Median score of 2 (at least 50% of responses are 2The lack of scientific evidence in the literature is described by or 1 and 2).the following terms: Strongly Disagree. Median score of 1 (at least 50% of re- sponses are 1).Inadequate: The available literature cannot be used to assess relationships among clinical interventions and clinical outcomes. The literature either does not Category C: Informal Opinion meet the criteria for content as defined in the “Fo- Open-forum testimony, Internet-based comments, letters, cus” of the Guidelines or does not permit a clear and editorials are all informally evaluated and discussed dur- interpretation of findings due to methodologic con- ing the development of Guideline recommendations. When cerns (e.g., confounding in study design or imple- warranted, the Task Force may add educational information mentation). or cautionary notes based on this information.Silent: No identified studies address the specified relation- Guidelines ships among interventions and outcomes. I. Resource PreparationOpinion-based Evidence Resource preparation includes (1) assessing the physical envi- ronment where central venous catheterization is planned to de-All opinion-based evidence relevant to each topic (e.g., survey data, termine the feasibility of using aseptic techniques, (2) availabil-open-forum testimony, Internet-based comments, letters, editori- ity of a standardized equipment set, (3) use of an assistant forals) is considered in the development of these Guidelines. However, central venous catheterization, and (4) use of a checklist or pro-only the findings obtained from formal surveys are reported. tocol for central venous catheter placement and maintenance. Opinion surveys were developed by the Task Force toaddress each clinical intervention identified in the docu- The literature is insufficient to specifically evaluate thement. Identical surveys were distributed to expert consul- effect of the physical environment for aseptic catheter inser-tants and ASA members, and a survey addressing selected tion, availability of a standardized equipment set, or the usepediatric issues was distributed to SPA members. of an assistant on outcomes associated with central venous catheterization (Category D evidence). An observational study reports that the implementation of a trauma intensive careCategory A: Expert Opinion unit multidisciplinary checklist is associated with reducedSurvey responses from Task Force-appointed expert consultants catheter-related infection rates (Category B2 evidence).1 Ob-are reported in summary form in the text, with a complete servational studies report reduced catheter-related blood-listing of consultant survey responses reported in appendix 5. stream infection rates when intensive care unit-wide bundled protocols are implemented (Category B2 evidence).2–7 TheseCategory B: Membership Opinion studies do not permit the assessment of the effect of anySurvey responses from active ASA and SPA members are re- single component of a checklist or bundled protocol on out-ported in summary form in the text, with a complete listing of come. The Task Force notes that the use of checklists in otherASA and SPA member survey responses reported in appendix 5. specialties or professions has been effective in reducing the error rate for a complex series of activities.8,9 Survey responses are recorded using a 5-point scale andsummarized based on median values.§ The consultants and ASA members strongly agree that cen- tral venous catheterization should be performed in a locationStrongly Agree. Median score of 5 (at least 50% of the that permits the use of aseptic techniques. The consultants and responses are 5). ASA members strongly agree that a standardized equipment setAgree. Median score of 4 (at least 50% of the responses are should be available for central venous access. The consultants 4 or 4 and 5). and ASA members agree that a trained assistant should be usedEquivocal. Median score of 3 (at least 50% of the responses during the placement of a central venous catheter. The ASA are 3, or no other response category or com- members agree and the consultants strongly agree that a check- bination of similar categories contain at list or protocol should be used for the placement and mainte- least 50% of the responses). nance of central venous catheters. § When an equal number of categorically distinct responses are Recommendations for Resource Preparation. Central ve-obtained, the median value is determined by calculating the arith- nous catheterization should be performed in an environ-metic mean of the two middle values. Ties are calculated by a ment that permits use of aseptic techniques. A standard-predetermined formula. ized equipment set should be available for central venous ࿣ Refer to appendix 2 for an example of a list of standardizedequipment for adult patients. access.࿣ A checklist or protocol should be used for place- # Refer to appendix 3 for an example of a checklist or protocol. ment and maintenance of central venous catheters.# An ** Refer to appendix 4 for an example of a list of duties per- assistant should be used during placement of a centralformed by an assistant. venous catheter.**Anesthesiology 2012; 116:539 –73 541 Practice Guidelines
  4. 4. Practice GuidelinesII. Prevention of Infectious Complications 100%), caps (100% and 94.7%), and masks covering bothInterventions intended to prevent infectious complica- the mouth and nose (100% and 98.1%).tions associated with central venous access include, but arenot limited to (1) intravenous antibiotic prophylaxis, (2)aseptic techniques (i.e., practitioner aseptic preparation Selection of Antiseptic Solutionand patient skin preparation), (3) selection of coated or Chlorhexidine solutions: A randomized controlled trial com-impregnated catheters, (4) selection of catheter insertion paring chlorhexidine (2% aqueous solution without alcohol)site, (5) catheter fixation method, (6) insertion site dress- with 10% povidone iodine (without alcohol) for skin prep-ings, (7) catheter maintenance procedures, and (8) aseptic aration reports equivocal findings regarding catheter coloni-techniques using an existing central venous catheter for zation (P ϭ 0.013) and catheter-related bacteremia (P ϭinjection or aspiration. 0.28) (Category C2 evidence).13 The literature is insufficient to evaluate chlorhexidine with alcohol compared with povi-Intravenous Antibiotic Prophylaxis. Randomized con- done-iodine with alcohol (Category D evidence). The litera-trolled trials indicate that catheter-related infections and ture is insufficient to evaluate the safety of antiseptic solu-sepsis are reduced when prophylactic intravenous antibi- tions containing chlorhexidine in neonates, infants andotics are administered to high-risk immunosuppressed children (Category D evidence).cancer patients or neonates (Category A2 evidence).10,11 Solutions containing alcohol: Comparative studies are in-The literature is insufficient to evaluate outcomes associ- sufficient to evaluate the efficacy of chlorhexidine with alco-ated with the routine use of intravenous antibiotics (Cat- hol in comparison with chlorhexidine without alcohol foregory D evidence). skin preparation during central venous catheterization (Cat- The consultants and ASA members agree that intrave- egory D evidence). A randomized controlled trial of povidone-nous antibiotic prophylaxis may be administered on a iodine with alcohol indicates that catheter tip colonization iscase-by-case basis for immunocompromised patients or reduced when compared with povidone-iodine alone (Cate-high-risk neonates. The consultants and ASA members gory A3 evidence); equivocal findings are reported for cathe-agree that intravenous antibiotic prophylaxis should not ter-related infection (P ϭ 0.04) and clinical signs of infectionbe administered routinely. (P ϭ 0.09) (Category C2 evidence).14Recommendations for Intravenous Antibiotic Prophylaxis. The consultants and ASA members strongly agree thatFor immunocompromised patients and high-risk neonates, chlorhexidine with alcohol should be used for skin prep-administer intravenous antibiotic prophylaxis on a case-by- aration. SPA members are equivocal regarding whethercase basis. Intravenous antibiotic prophylaxis should not be chlorhexidine-containing solutions should be used foradministered routinely. skin preparation in neonates (younger than 44 gestational weeks); they agree with the use of chlorhexidine in infants (younger than 2 yr) and strongly agree with its use inAseptic Preparation and Selection of Antiseptic Solution children (2–16 yr).Aseptic preparation of practitioner, staff, and patients: A ran-domized controlled trial comparing maximal barrier precau-tions (i.e., mask, cap, gloves, gown, large full-body drape) Recommendations for Aseptic Preparation and Selectionwith a control group (i.e., gloves and small drape) reported of Antiseptic Solutionequivocal findings for reduced colonization (P ϭ 0.03) and In preparation for the placement of central venous catheters,catheter-related septicemia (P ϭ 0.06) (Category C2 evi- use aseptic techniques (e.g., hand washing) and maximal bar-dence).12 The literature is insufficient to evaluate the efficacy rier precautions (e.g., sterile gowns, sterile gloves, caps, masksof specific aseptic activities (e.g., hand washing) or barrier covering both mouth and nose, and full-body patientprecautions (e.g., sterile full-body drapes, sterile gown, drapes). A chlorhexidine-containing solution should be usedgloves, mask, cap) (Category D evidence). Observational stud- for skin preparation in adults, infants, and children; for ne-ies report hand washing, sterile full-body drapes, sterile onates, the use of a chlorhexidine-containing solution forgloves, caps, and masks as elements of care “bundles” that skin preparation should be based on clinical judgment andresult in reduced catheter-related bloodstream infections institutional protocol. If there is a contraindication to chlo-(Category B2 evidence).2–7 However, the degree to which each rhexidine, povidone-iodine or alcohol may be used. Unlessparticular element contributed to improved outcomes could contraindicated, skin preparation solutions should containnot be determined. alcohol. Most consultants and ASA members indicated that the Catheters Containing Antimicrobial Agents. Meta-analysisfollowing aseptic techniques should be used in preparation of randomized controlled trials15–19 comparing antibiotic-for the placement of central venous catheters: hand washing coated with uncoated catheters indicates that antibiotic-(100% and 96%); sterile full-body drapes (87.3% and coated catheters reduce catheter colonization (Category A173.8%); sterile gowns (100% and 87.8%), gloves (100% and evidence). Meta-analysis of randomized controlled trials20 –24Anesthesiology 2012; 116:539 –73 542 Practice Guidelines
  5. 5. SPECIAL ARTICLEScomparing silver-impregnated catheters with uncoated cath- Recommendations for Selection of Catheter Insertion Site.eters report equivocal findings for catheter-related blood- Catheter insertion site selection should be based on clin-stream infection (Category C1 evidence); randomized con- ical need. An insertion site should be selected that is nottrolled trials were equivocal regarding catheter colonization contaminated or potentially contaminated (e.g., burned or(P ϭ 0.16 – 0.82) (Category C2 evidence).20 –22,24 Meta-anal- infected skin, inguinal area, adjacent to tracheostomy oryses of randomized controlled trials25–36 demonstrate that open surgical wound). In adults, selection of an uppercatheters coated with chlorhexidine and silver sulfadiazine body insertion site should be considered to minimize thereduce catheter colonization (Category A1 evidence); equivo- risk of infection.cal findings are reported for catheter-related bloodstream in- Catheter Fixation. The literature is insufficient to evaluatefection (i.e., catheter colonization and corresponding posi- whether catheter fixation with sutures, staples or tape is as-tive blood culture) (Category C1 evidence).25–27,29 –35,37,38 sociated with a higher risk for catheter-related infectionsCases of anaphylactic shock are reported after placement of a (Category D evidence).catheter coated with chlorhexidine and silver sulfadiazine Most consultants and ASA members indicate that use of(Category B3 evidence).39 – 41 sutures is the preferred catheter fixation technique to mini- Consultants and ASA members agree that catheters coated mize catheter-related infection.with antibiotics or a combination of chlorhexidine and silver Recommendations for Catheter Fixation. The use of su-sulfadiazine may be used in selected patients based on infectious tures, staples, or tape for catheter fixation should be deter-risk, cost, and anticipated duration of catheter use. mined on a local or institutional basis.Recommendations for Use of Catheters Containing Anti- Insertion Site Dressings. The literature is insufficient tomicrobial Agents. Catheters coated with antibiotics or a evaluate the efficacy of transparent bio-occlusive dressingscombination of chlorhexidine and silver sulfadiazine should to reduce the risk of infection (Category D evidence). Ran-be used for selected patients based on infectious risk, cost, domized controlled trials are equivocal (P ϭ 0.04 – 0.96)and anticipated duration of catheter use. The Task Force regarding catheter tip colonization50,51 and inconsistentnotes that catheters containing antimicrobial agents are not a (P ϭ 0.004 – 0.96) regarding catheter-related blood-substitute for additional infection precautions. stream infection50,52 when chlorhexidine sponge dressingsSelection of Catheter Insertion Site. A randomized con- are compared with standard polyurethane dressings (Cate-trolled trial comparing the subclavian and femoral insertion gory C2 evidence). A randomized controlled trial is also equiv-sites report higher levels of catheter colonization with the ocal regarding catheter tip colonization for silver-impreg-femoral site (Category A3 evidence); equivocal findings are nated transparent dressings compared with standardreported for catheter-related sepsis (P ϭ 0.07) (Category C2 dressings (P Ͼ 0.05) (Category C2 evidence).53 A randomizedevidence).42 A randomized controlled trial comparing the in- controlled trial reports a greater frequency of severe localizedternal jugular insertion site with the femoral site reports no contact dermatitis when neonates receive chlorhexidine-im-difference in catheter colonization (P ϭ 0.79) or catheter pregnated dressings compared with povidone-iodine im-related bloodstream infections (P ϭ 0.42) (Category C2 evi- pregnated dressings (Category A3 evidence).54dence).43 Prospective nonrandomized comparative studies The ASA members agree and the consultants stronglyare equivocal (i.e., inconsistent) regarding catheter-related agree that transparent bio-occlusive dressings should be usedcolonization44 – 46 and catheter related bloodstream infec- to protect the site of central venous catheter insertion fromtion46 – 48 when the internal jugular site is compared with the infection. The consultants and ASA members agree thatsubclavian site (Category C3 evidence). A nonrandomized dressings containing chlorhexidine may be used to reduce thecomparative study of burn patients reports that catheter col- risk of catheter-related infection. SPA members are equivocalonization and bacteremia occur more frequently the closer regarding whether dressings containing chlorhexidine maythe catheter insertion site is to the burn wound (Category B1 be used for skin preparation in neonates (younger than 44evidence).49 gestational weeks); they agree that the use of dressings con- Most consultants indicate that the subclavian insertion taining chlorhexidine may be used in infants (younger than 2site is preferred to minimize catheter-related risk of infec- yr) and children (2–16 yr).tion. Most ASA members indicate that the internal jugular Recommendations for Insertion Site Dressings. Transpar-insertion site is preferred to minimize catheter-related ent bio-occlusive dressings should be used to protect therisk of infection. The consultants and ASA members agree site of central venous catheter insertion from infection.that femoral catheterization should be avoided when pos- Unless contraindicated, dressings containing chlorhexi-sible to minimize the risk of infection. The consultants dine may be used in adults, infants, and children. Forand ASA members strongly agree that an insertion site neonates, the use of transparent or sponge dressings con-should be selected that is not contaminated or potentially taining chlorhexidine should be based on clinical judg-contaminated. ment and institutional protocol.Anesthesiology 2012; 116:539 –73 543 Practice Guidelines
  6. 6. Practice GuidelinesCatheter Maintenance. Catheter maintenance consists of (1) connectors with standard caps indicate decreased levels ofdetermining the optimal duration of catheterization, (2) con- microbial contamination of stopcock entry ports withducting catheter site inspections, (3) periodically changing needleless connectors (Category A2 evidence);63,64 no differ-catheters, and (4) changing catheters using a guidewire in- ences in catheter-related bloodstream infection are reportedstead of selecting a new insertion site. (P ϭ 0.3– 0.9) (Category C2 evidence).65,66 Nonrandomized comparative studies indicate that longer The consultants and ASA members strongly agree thatcatheterizations are associated with higher rates of catheter catheter access ports should be wiped with an appropriatecolonization, infection, and sepsis (Category B2 evi- antiseptic before each access. The consultants and ASA mem-dence).45,55 The literature is insufficient to evaluate whether bers agree that needleless ports may be used on a case-by-casespecified time intervals between catheter site inspections are basis. The consultants and ASA members strongly agree thatassociated with a higher risk for catheter-related infection central venous catheter stopcocks should be capped when not(Category D evidence). Randomized controlled trials report in use.equivocal findings (P ϭ 0.54 – 0.63) regarding differences in Recommendations for Aseptic Techniques Using an Ex-catheter tip colonizations when catheters are changed at 3- isting Central Line. Catheter access ports should be wipedversus 7-day intervals (Category C2 evidence).56,57 Meta-anal- with an appropriate antiseptic before each access when usingysis of randomized controlled trials58 – 62 report equivocal an existing central venous catheter for injection or aspiration.findings for catheter tip colonization when guidewires are Central venous catheter stopcocks or access ports should beused to change catheters compared with the use of new in- capped when not in use. Needleless catheter access ports maysertion sites (Category C1 evidence). be used on a case-by-case basis. The ASA members agree and the consultants stronglyagree that the duration of catheterization should be based on III. Prevention of Mechanical Trauma or Injuryclinical need. The consultants and ASA members strongly Interventions intended to prevent mechanical trauma oragree that (1) the clinical need for keeping the catheter in injury associated with central venous access include, butplace should be assessed daily; (2) catheters should be are not limited to (1) selection of catheter insertion site,promptly removed when deemed no longer clinically neces- (2) positioning the patient for needle insertion and cath-sary; (3) the catheter site should be inspected daily for signs of eter placement, (3) needle insertion and catheter place-infection and changed when infection is suspected; and (4) ment, and (4) monitoring for needle, guidewire, and cath-when catheter infection is suspected, replacing the catheter eter placement.using a new insertion site is preferable to changing the cath- 1. Selection of Catheter Insertion Site. A randomized con-eter over a guidewire. trolled trial comparing the subclavian and femoral insertionRecommendations for Catheter Maintenance. The dura- sites reports that the femoral site had a higher frequency oftion of catheterization should be based on clinical need. The thrombotic complications in adult patients (Category A3 ev-clinical need for keeping the catheter in place should be as- idence).42 A randomized controlled trial comparing the in-sessed daily. Catheters should be removed promptly when no ternal jugular insertion site with the femoral site reportslonger deemed clinically necessary. The catheter insertion equivocal findings for arterial puncture (P ϭ 0.35), deepsite should be inspected daily for signs of infection, and the venous thrombosis (P ϭ 0.62) or hematoma formation (P ϭcatheter should be changed or removed when catheter inser- 0.47) (Category C2 evidence).43 A randomized controlled trialtion site infection is suspected. When a catheter related in- comparing the internal jugular insertion site with the subcla-fection is suspected, replacing the catheter using a new inser- vian site reports equivocal findings for successful veni-tion site is preferable to changing the catheter over a puncture (P ϭ 0.03) (Category C2 evidence).67 Nonran-guidewire. domized comparative studies report equivocal findings for arterial puncture, pneumothorax, hematoma, hemotho-Aseptic Techniques Using an Existing Central Venous rax, or arrhythmia when the internal jugular insertion siteCatheter for Injection or Aspiration is compared with the subclavian insertion site (Category C3 evidence).68 –70Aseptic techniques using an existing central venous catheterfor injection or aspiration consist of (1) wiping the port with Most consultants and ASA members indicate that thean appropriate antiseptic, (2) capping stopcocks or access internal jugular insertion site is preferred to minimizeports, and (3) use of needleless catheter connectors or access catheter cannulation-related risk of injury or trauma.ports. Most consultants and ASA members also indicate that the The literature is insufficient to evaluate whether wiping internal jugular insertion site is preferred to minimizeports or capping stopcocks when using an existing central catheter-related risk of thromboembolic injury or trauma.venous catheter for injection or aspiration is associated with a Recommendations for Catheter Insertion Site Selection.reduced risk for catheter-related infections (Category D evi- Catheter insertion site selection should be based ondence). Randomized controlled trials comparing needleless clinical need and practitioner judgment, experience, andAnesthesiology 2012; 116:539 –73 544 Practice Guidelines
  7. 7. SPECIAL ARTICLESskill. In adults, selection of an upper body insertion site tion, and the skill and experience of the operator. Theshould be considered to minimize the risk of thrombotic consultants and ASA members agree that the selection of acomplications. modified Seldinger technique versus a Seldinger technique2. Positioning the Patient for Needle Insertion and Cath- should be based on the clinical situation and the skill andeter Placement. Nonrandomized studies comparing the Tren- experience of the operator. The consultants and ASAdelenburg (i.e., head down) position with the normal supine members agree that the number of insertion attemptsposition indicates that the right internal jugular vein increases in should be based on clinical judgment. The ASA membersdiameter and cross-sectional area to a greater extent when adult agree and the consultants strongly agree that the decisionpatients are placed in the Trendelenburg position (Category B2 to place two central catheters in a single vein should beevidence).71–76 One nonrandomized study comparing the Tren- made on a case-by-case basis.delenburg position with the normal supine position in pediatric Recommendations for Needle Insertion, Wire Placement,patients reports an increase in right internal jugular vein diam- and Catheter Placement. Selection of catheter size (i.e.,eter only for patients older than 6 yr (Category B2 evidence).77 outside diameter) and type should be based on the clinical The consultants and ASA members strongly agree that, situation and skill/experience of the operator. Selection ofwhen clinically appropriate and feasible, central vascular ac- the smallest size catheter appropriate for the clinical situ-cess in the neck or chest should be performed with the patient ation should be considered. Selection of a thin-wall needlein the Trendelenburg position. (i.e., Seldinger) technique versus a catheter-over-the-nee- dle (i.e., modified Seldinger) technique should be based on the clinical situation and the skill/experience of theRecommendations for Positioning the Patient for Needle operator. The decision to use a thin-wall needle techniqueInsertion and Catheter Placement or a catheter-over-the-needle technique should be based atWhen clinically appropriate and feasible, central venous ac- least in part on the method used to confirm that the wirecess in the neck or chest should be performed with the patient resides in the vein before a dilator or large-bore catheter isin the Trendelenburg position. threaded (fig. 1). The Task Force notes that the catheter- over-the-needle technique may provide more stable ve-3. Needle Insertion, Wire Placement, and Catheter Place- nous access if manometry is used for venous confirmation.ment. Needle insertion, wire placement, and catheter place- The number of insertion attempts should be based onment includes (1) selection of catheter size and type, (2) use of a clinical judgment. The decision to place two catheters in awire-through-thin-wall needle technique (i.e., Seldinger tech- single vein should be made on a case-by-case basis.nique) versus a catheter-over-the-needle-then-wire-through- 4. Guidance and Verification of Needle, Wire, and Catheterthe-catheter technique (i.e., modified Seldinger technique), (3) Placement. Guidance for needle, wire, and catheter placementlimiting the number of insertion attempts, and (4) introducing includes ultrasound imaging for the purpose of prepuncturetwo catheters in the same central vein. vessel localization (i.e., static ultrasound) and ultrasound for Case reports describe severe injury (e.g., hemorrhage, he- vessel localization and guiding the needle to its intended venousmatoma, pseudoaneurysm, arteriovenous fistula, arterial dis- location (i.e., real time or dynamic ultrasound). Verification ofsection, neurologic injury including stroke, and severe or needle, wire, or catheter location includes any one or more of thelethal airway obstruction) when there is unintentional ar- following methods: (1) ultrasound, (2) manometry, (3) pressureterial cannulation with large bore catheters (Category B3 waveform analysis, (4) venous blood gas, (5) fluoroscopy, (6)evidence).78 – 88 The literature is insufficient to evaluate continuous electrocardiography, (7) transesophageal echocardi-whether the risk of injury or trauma is associated with the ography, and (8) chest radiography.use of a thin-wall needle technique versus a catheter-over-the needle technique (Category D evidence). The literatureis insufficient to evaluate whether the risk of injury or Guidancetrauma is related to the number of insertion attempts Static Ultrasound. Randomized controlled trials comparing(Category D evidence). One nonrandomized comparative static ultrasound with the anatomic landmark approach for lo-study reports a higher frequency of dysrhythmia when two cating the internal jugular vein report a higher first insertioncentral venous catheters are placed in the same vein (right attempt success rate for static ultrasound (Category A3 evi-internal jugular) compared with placement of one cathe- dence);90 findings are equivocal regarding overall successful can-ter in the vein (Category B2 evidence); no differences in nulation rates (P ϭ 0.025– 0.57) (Category C2 evidence).90 –92 Incarotid artery puncture (P ϭ 0.65) or hematoma (P ϭ addition, the literature is equivocal regarding subclavian vein0.48) were noted (Category C3 evidence).89 access (P ϭ 0.84) (Category C2 evidence) 93 and insufficient for The consultants agree and the ASA members strongly femoral vein access (Category D evidence).agree that the selection of catheter type (i.e., gauge, The consultants and ASA members agree that static ultra-length, number of lumens) and composition (e.g., poly- sound imaging should be used in elective situations for pre-urethane, Teflon) should be based on the clinical situa- puncture identification of anatomy and vessel localizationAnesthesiology 2012; 116:539 –73 545 Practice Guidelines
  8. 8. Practice GuidelinesFig. 1. Algorithm for central venous insertion and verification. This algorithm compares the thin-wall needle (i.e., Seldinger)technique versus the catheter-over-the needle (i.e., Modified-Seldinger) technique in critical safety steps to prevent uninten-tional arterial placement of a dilator or largebore catheter. The variation between the two techniques reflects mitigation stepsfor the risk that the thin-wall needle in the Seldinger technique could move out of the vein and into the wall of an artery betweenthe manometry step and the threading of the wire step. ECG ϭ electrocardiography; TEE ϭ transesophageal echocardiography.when the internal jugular vein is selected for cannulation; Real-time Ultrasound. Meta-analysis of randomized con-they are equivocal regarding whether static ultrasound imag- trolled trials94 –104 indicates that, compared with the ana-ing should be used when the subclavian vein is selected. The tomic landmark approach, real-time ultrasound guided ve-consultants agree and the ASA members are equivocal re- nipuncture of the internal jugular vein has a highergarding the use of static ultrasound imaging when the fem- first insertion attempt success rate, reduced access time,oral vein is selected. higher overall successful cannulation rate, and decreasedAnesthesiology 2012; 116:539 –73 546 Practice Guidelines
  9. 9. SPECIAL ARTICLESrates of arterial puncture (Category A1 evidence). identifying the position of the catheter tip (Category B2 evi-Randomized controlled trials report fewer number of dence). Randomized controlled trials indicate that continu-insertion attempts with real-time ultrasound guided ous electrocardiography is effective in identifying propervenipuncture of the internal jugular vein (Category A2 catheter tip placement compared with not using electrocar-evidence).97,99,103,104 diography (Category A2 evidence).115,126,127 For the subclavian vein, randomized controlled trials report The consultants and ASA members strongly agree thatfewer insertion attempts with real-time ultrasound guided veni- before insertion of a dilator or large- bore catheter over apuncture (Category A2 evidence),105,106 and one randomized wire, venous access should be confirmed for the catheter orclinical trial indicates a higher success rate and reduced access thin-wall needle that accesses the vein. The Task Force be-time, with fewer arterial punctures and hematomas compared lieves that blood color or absence of pulsatile flow should notwith the anatomic landmark approach (Category A3 evi- be relied upon to confirm venous access. The consultantsdence).106 agree and ASA members are equivocal that venous access For the femoral vein, a randomized controlled trial re- should be confirmed for the wire that subsequently resides inports a higher first-attempt success rate and fewer needle the vein after traveling through a catheter or thin-wall needlepasses with real-time ultrasound guided venipuncture com- before insertion of a dilator or large-bore catheter over a wire.pared with the anatomic landmark approach in pediatric The consultants and ASA members agree that, when feasible,patients (Category A3 evidence).107 both the location of the catheter or thin-wall needle and wire The consultants agree and the ASA members are equivocal that, should be confirmed.when available, real time ultrasound should be used for The consultants and ASA members agree that a chestguidance during venous access when either the internal radiograph should be performed to confirm the location ofjugular or femoral veins are selected for cannulation. The the catheter tip as soon after catheterization as clinically ap-consultants and ASA members are equivocal regarding the propriate. They also agree that, for central venous cathetersuse of real time ultrasound when the subclavian vein is placed in the operating room, a confirmatory chest radio-selected. graph may be performed in the early postoperative period. The ASA members agree and the consultants strongly agree that, if a chest radiograph is deferred to the postoperativeVerification period, pressure waveform analysis, blood gas analysis, ultra-Confirming that the Catheter or Thin-wall Needle Resides sound, or fluoroscopy should be used to confirm venousin the Vein. A retrospective observational study reports that positioning of the catheter before use.manometry can detect arterial punctures not identified by bloodflow and color (Category B2 evidence).108 The literature is insuf- Recommendations for Guidance and Verification officient to address ultrasound, pressure-waveform analysis, blood Needle, Wire, and Catheter Placementgas analysis, blood color, or the absence of pulsatile flow as The following steps are recommended for prevention of me-effective methods of confirming catheter or thin-wall needle chanical trauma during needle, wire, and catheter placementvenous access (Category D evidence). in elective situations:Confirming Venous Residence of the Wire. An observational ● Use static ultrasound imaging before prepping andstudy indicates that ultrasound can be used to confirm venous draping for prepuncture identification of anatomy toplacement of the wire before dilation or final catheterization determine vessel localization and patency when the in-(Category B2 evidence).109 Case reports indicate that transesoph- ternal jugular vein is selected for cannulation. Staticageal echocardiography was used to identify guidewire position ultrasound may be used when the subclavian or femoral(Category B3 evidence).110 –112 The literature is insufficient to vein is selected.evaluate the efficacy of continuous electrocardiography in con- ● Use real time ultrasound guidance for vessel localizationfirming venous residence of the wire (Category D evidence), al- and venipuncture when the internal jugular vein is selectedthough narrow complex electrocardiographic ectopy is recog- for cannulation (see fig. 1). Real-time ultrasound may benized by the Task Force as an indicator of venous location of the used when the subclavian or femoral vein is selected. Thewire. The literature is insufficient to address fluoroscopy as an Task Force recognizes that this approach may not be fea-effective method to confirm venous residence of the wire (Cat- sible in emergency circumstances or in the presence ofegory D evidence); the Task Force believes that fluoroscopy may other clinical constraints.be used.Confirming Residence of the Catheter in the Venous Sys- ● After insertion of a catheter that went over the needle or atem. Studies with observational findings indicate that fluo- thin-wall needle, confirm venous access.†† Methods for confirming that the catheter or thin-wall needle resides inroscopy113,115 and chest radiography115–125 are useful in the vein include, but are not limited to, ultrasound, ma- †† For neonates, infants, and children, confirmation of venous nometry, pressure-waveform analysis, or venous blood gasplacement may take place after the wire is threaded. measurement. Blood color or absence of pulsatile flowAnesthesiology 2012; 116:539 –73 547 Practice Guidelines
  10. 10. Practice Guidelines should not be relied upon for confirming that the catheter nonsurgically, as follows: 54.9% (for neonates), 43.8% (for in- or thin-wall needle resides in the vein. fants), and 30.0% (for children). SPA members indicating that● When using the thin-wall needle technique, confirm the catheter may be nonsurgically removed without consulta- venous residence of the wire after the wire is threaded. tion is as follows: 45.1% (for neonates), 56.2% (for infants), and When using the catheter-over-the-needle technique, 70.0% (for children). The Task Force agrees that the anesthesi- confirmation that the wire resides in the vein may not be ologist and surgeon should confer regarding the relative risks needed (1) when the catheter enters the vein easily and and benefits of proceeding with elective surgery after an arterial manometry or pressure waveform measurement pro- vessel has sustained unintended injury by a dilator or large-bore vides unambiguous confirmation of venous location of catheter. the catheter; and (2) when the wire passes through the Recommendations for Management of Arterial Trauma or catheter and enters the vein without difficulty. If there is Injury Arising from Central Venous Access. When unin- any uncertainty that the catheter or wire resides in the tended cannulation of an arterial vessel with a dilator or vein, confirm venous residence of the wire after the wire large-bore catheter occurs, the dilator or catheter should is threaded. Insertion of a dilator or large-bore catheter be left in place and a general surgeon, a vascular surgeon, may then proceed. Methods for confirming that the wire or an interventional radiologist should be immediately resides in the vein include, but are not limited to, ultra- consulted regarding surgical or nonsurgical catheter re- sound (identification of the wire in the vein) or trans- moval for adults. For neonates, infants, and children the esophageal echocardiography (identification of the wire decision to leave the catheter in place and obtain consul- in the superior vena cava or right atrium), continuous tation or to remove the catheter nonsurgically should be electrocardiography (identification of narrow-complex based on practitioner judgment and experience. After the ectopy), or fluoroscopy. injury has been evaluated and a treatment plan has been● After final catheterization and before use, confirm resi- executed, the anesthesiologist and surgeon should confer dence of the catheter in the venous system as soon as regarding relative risks and benefits of proceeding with the clinically appropriate. Methods for confirming that the elective surgery versus deferring surgery to allow for a pe- catheter is still in the venous system after catheterization riod of patient observation. and before use include manometry or pressure wave- form measurement.● Confirm the final position of the catheter tip as soon as Appendix 1: Summary of clinically appropriate. Methods for confirming the position of Recommendations the catheter tip include chest radiography, fluoroscopy, or Resource Preparation continuous electrocardiography. For central venous catheters placed in the operating room, perform the chest radiograph ● Central venous catheterization should be performed in an envi- no later than the early postoperative period to confirm the ronment that permits use of aseptic techniques. position of the catheter tip. ● A standardized equipment set should be available for central ve- nous access. ● A checklist or protocol should be used for placement and main-IV. Management of Arterial Trauma or Injury Arising tenance of central venous catheters.from Central Venous Catheterization ● An assistant should be used during placement of a central venousCase reports of adult patients with arterial puncture by a catheter.large bore catheter/vessel dilator during attempted centralvenous catheterization indicate severe complications (e.g., Prevention of Infectious Complicationscerebral infarction, arteriovenous fistula, hemothorax) af- • For immunocompromised patients and high-risk neonates,ter immediate catheter removal; no such complications administer intravenous antibiotic prophylaxis on a case-by-were reported for adult patients whose catheters were left case basis.in place before surgical consultation and repair (Category ⅙ Intravenous antibiotic prophylaxis should not be adminis-B3 evidence).80,86 tered routinely. The consultants and ASA members agree that, when unin- • In preparation for the placement of central venous catheters, usetended cannulation of an arterial vessel with a large-bore cathe- aseptic techniques (e.g., hand washing) and maximal barrier pre-ter occurs, the catheter should be left in place and a general cautions (e.g., sterile gowns, sterile gloves, caps, masks coveringsurgeon or vascular surgeon should be consulted. When unin- both mouth and nose, and full-body patient drapes).tended cannulation of an arterial vessel with a large-bore cathe- • A chlorhexidine-containing solution should be used for skinter occurs, the SPA members indicate that the catheter should be preparation in adults, infants, and children.left in place and a general surgeon, vascular surgeon, or inter- ⅙ For neonates, the use of a chlorhexidine-containing solutionventional radiologist should be immediately consulted before for skin preparation should be based on clinical judgment anddeciding on whether to remove the catheter, either surgically or institutional protocol.Anesthesiology 2012; 116:539 –73 548 Practice Guidelines
  11. 11. SPECIAL ARTICLES ⅙ If there is a contraindication to chlorhexidine, povidone-io- ⅙ In adults, selection of an upper body insertion site should dine or alcohol may be used as alternatives. be considered to minimize the risk of thrombotic ⅙ Unless contraindicated, skin preparation solutions should complications. contain alcohol. • When clinically appropriate and feasible, central venous access in• If there is a contraindication to chlorhexidine, povidone-iodine the neck or chest should be performed with the patient in the or alcohol may be used. Unless contraindicated, skin preparation Trendelenburg position. solutions should contain alcohol. • Selection of catheter size (i.e., outside diameter) and type• Catheters coated with antibiotics or a combination of chlo- should be based on the clinical situation and skill/experience rhexidine and silver sulfadiazine should be used for selected of the operator. patients based on infectious risk, cost, and anticipated dura- ⅙ Selection of the smallest size catheter appropriate for the tion of catheter use. clinical situation should be considered. ⅙ Catheters containing antimicrobial agents are not a substi- • Selection of a thin-wall needle (a wire-through-thin-wall-needle, tute for additional infection precautions. or Seldinger) technique versus a catheter-over-the-needle (a cath- eter-over-the-needle-then-wire-through-the-catheter, or Modi-• Catheter insertion site selection should be based on clinical fied Seldinger) technique should be based on the clinical situation need. and the skill/experience of the operator. ⅙ An insertion site should be selected that is not contami- ⅙ The decision to use a thin-wall needle technique or a cath- nated or potentially contaminated (e.g., burned or infected eter-over-the-needle technique should be based at least in skin, inguinal area, adjacent to tracheostomy or open sur- part on the method used to confirm that the wire resides in gical wound). the vein before a dilator or large-bore catheter is ⅙ In adults, selection of an upper body insertion site should threaded. be considered to minimize the risk of infection. ⅙ The catheter-over-the-needle technique may provide• The use of sutures, staples, or tape for catheter fixation should be more stable venous access if manometry is used for venous determined on a local or institutional basis. confirmation.• Transparent bio-occlusive dressings should be used to protect • The number of insertion attempts should be based on clinical the site of central venous catheter insertion from infection. judgment. ⅙ Unless contraindicated, dressings containing chlorhexidine • The decision to place two catheters in a single vein should be may be used in adults, infants, and children. made on a case-by-case basis. ⅙ For neonates, the use of transparent or sponge dressings • Use static ultrasound imaging in elective situations before prep- containing chlorhexidine should be based on clinical judg- ping and draping for prepuncture identification of anatomy to ment and institutional protocol. determine vessel localization and patency when the internal jug-• The duration of catheterization should be based on clinical ular vein is selected for cannulation. need. ⅙ Static ultrasound may be used when the subclavian or femoral ⅙ The clinical need for keeping the catheter in place should be vein is selected. assessed daily. • Use real-time ultrasound guidance for vessel localization and ⅙ Catheters should be removed promptly when no longer venipuncture when the internal jugular vein is selected for deemed clinically necessary. cannulation.• The catheter insertion site should be inspected daily for signs of ⅙ Real-time ultrasound may be used when the subclavian or infection. femoral vein is selected. ⅙ Real-time ultrasound may not be feasible in emergency ⅙ The catheter should be changed or removed when catheter circumstances or in the presence of other clinical insertion site infection is suspected. constraints.• When a catheter-related infection is suspected, replacing the • After insertion of a catheter that went over the needle or a catheter using a new insertion site is preferable to changing the thin-wall needle, confirm venous access.†† catheter over a guidewire. ⅙ Methods for confirming that the catheter or thin-wall nee-• Catheter access ports should be wiped with an appropriate anti- dle resides in the vein include, but are not limited to: ultra- septic before each access when using an existing central venous sound, manometry, pressure-waveform analysis, or venous catheter for injection or aspiration. blood gas measurement.• Central venous catheter stopcocks or access ports should be ⅙ Blood color or absence of pulsatile flow should not be relied capped when not in use. upon for confirming that the catheter or thin-wall needle• Needleless catheter access ports may be used on a case-by-case resides in the vein. basis. • When using the thin-wall needle technique, confirm venous res- idence of the wire after the wire is threaded. • When using the catheter-over-the-needle technique, confir-Prevention of Mechanical Trauma or Injury mation that the wire resides in the vein may not be needed (1)• Catheter insertion site selection should be based on clinical need when the catheter enters the vein easily and manometry or and practitioner judgment, experience, and skill. pressure waveform measurement provides unambiguous con-Anesthesiology 2012; 116:539 –73 549 Practice Guidelines
  12. 12. Practice Guidelines firmation of venous location of the catheter, and (2) when the Appendix 2. Example of a Standardized Equipment wire passes through the catheter and enters the vein without Cart for Central Venous Catheterization for Adult difficulty. Patients ⅙ If there is any uncertainty that the catheter or wire resides in the Item Description Quantity vein, confirm venous residence of the wire after the wire is threaded. Insertion of a dilator or large-bore catheter may then First Drawer proceed. Bottles Alcohol-based Hand Cleanser 2 ⅙ Methods for confirming that the wire resides in the vein Transparent bio-occlusive dressings with catheter 2 include, but are not limited to surface ultrasound (identifi- stabilizer devices cation of the wire in the vein) or transesophageal echocar- Transducer kit: NaCL 0.9% 500 ml bag; single- 1 diography (identification of the wire in the superior vena line transducer, pressure bag cava or right atrium), continuous electrocardiography Needle Holder, Webster Disposable 5 inch 1 (identification of narrow-complex ectopy), or fluoroscopy. Scissors, 4 1/2 inchSterile 1• After final catheterization and before use, confirm residence of Vascular Access Tray(Chloraprep, Sponges, 1 the catheter in the venous system as soon as clinically Labels) Disposable pen with sterile labels 4 appropriate. Sterile tubing, arterial line pressure-rated (for 2 ⅙ Methods for confirming that the catheter is still in the manometry) venous system after catheterization and before use include Intravenous connector with needleless valve 4 waveform manometry or pressure measurement. Second Drawer• Confirm the final position of the catheter tip as soon as clin- ically appropriate. Ultrasound Probe Cover, Sterile 3 ϫ 96 2 Applicator, chloraprep 10.5 ml 3 ⅙ Methods for confirming the position of the catheter tip Surgical hair clipper blade 3 include chest radiography, fluoroscopy, or continuous Solution, NaCl bacteriostatic 30 ml 2 electrocardiography. Third Drawer• For central venous catheters placed in the operating room, per- form the chest radiograph no later than the early postoperative Cap, Nurses Bouffant 3 Surgeon hats 6 period to confirm the position of the catheter tip. Goggles 2 Mask, surgical fluidshield 2 Gloves, sterile sizes 6.0–8.0 (2 each size) 10Management of Arterial Trauma or Injury Arising from Packs, sterile gowns 2Central Venous Catheterization Fourth Drawer• When unintended cannulation of an arterial vessel with a dilator or large-bore catheter occurs, the dilator or catheter should be left Drape, Total Body (with Femoral Window) 1 in place and a general surgeon, a vascular surgeon, or an interven- Sheet, central line total body (no window) 1 tional radiologist should be immediately consulted regarding sur- Fifth Drawer gical or nonsurgical catheter removal for adults. Dressing, Sterile Sponge Packages 4 ⅙ For neonates, infants, and children, the decision to leave the Catheter kit, central venous pressure single 1 catheter in place and obtain consultation or to remove the lumen14 gauge catheter nonsurgically should be based on practitioner judg- Catheter kits, central venous pressure two 2 ment and experience. lumens 16 cm 7 French• After the injury has been evaluated and a treatment plan Sixth Drawer has been executed, the anesthesiologist and surgeon should Triple Lumen Centravel Venous Catheter Sets, 2 confer regarding relative risks and benefits of proceeding with 7 French Antimicrobial Impregnated the elective surgery versus deferring surgery for a period of Introducer catheter sets, 9 French with sideport 2 patient observation.Anesthesiology 2012; 116:539 –73 550 Practice Guidelines
  13. 13. SPECIAL ARTICLESAppendix 3. Example of a Central Venous Catheterization Checklist Central Line Insertion Standard Work & Safety (Bundle) Checklist for OR and CCU Date: __________________________ Start Time: ________________ End Time: _______________ Procedure Operator: ______________________ Person Completing Form: ______________________ Catheter Type: Central Venous PA/Swan-Ganz French Size of catheter: _______________ . Catheter lot number: _______________ Number of Lumens: 1 2 3 4 Insertion Site: Jugular Upper Arm Subclavian Femoral Side of Body: Left Right Bilateral Clinical Setting: Elective Emergent 1. Consent form complete and in chart Exception: Emergent procedure 2. Patient’s Allergy Assessed (especially to Lidocaine or Heparin) 3. Patient’s Latex Allergy Assessed (modify supplies) 4. Hand Hygiene: Operator and Assistant cleanse hands (ASK, if not witnessed) 5. Optimal Catheter Site Selection: In adults, Consider Upper Body Site Check / explain why femoral site used: ________________________________ OR Anatomy – distorted, prior surgery/rad. Scar Chest wall infection or burn Exception(s) Coagulopathy COPD severe/ lung disease checked to left Emergency / CPR Pediatric 6. Pre-procedure Ultrasound Check of internal jugular location and patency if IJ 7. Skin Prep Performed (Skin Antisepsis): Chloraprep 10.5 ml applicator used Dry technique (normal, unbroken skin): 30 second scrub + 30 second dry DRY time WET Wet technique (abnormal or broken skin): 2 minute scrub + 1 minute dry time 8. MAXIMUM Sterile Barriers: Operator wearing hat, mask, sterile gloves, and sterile gown Others in room, (except patient) wearing mask Patient’s body covered by sterile drape 9. Procedural “Time out” performed: Patient ID X 2 Procedure to be performed has been announced Insertion site marked Patient positioned correctly for procedure (Supine or Trendelenburg) Assembled equipment/ supplies including venous confirmation method verified Labels on all medication & syringes are verified (continued)Anesthesiology 2012; 116:539 –73 551 Practice Guidelines
  14. 14. Practice GuidelinesAppendix 3. Continued 10. Ultrasound Guidance Used for Elective Internal Jugular insertions (sterile Used for IJ probe cover in place) Not used (Other site used) 11. Confirmation of Venous Placement of Access Needle or Catheter: (do not Manometry rely on blood color or presence/absence of pulsatility) Ultrasound Transducer Blood Gas 12. Confirmation of Venous Placement of the Wire: Access catheter easily in vein & confirmed (catheter-over needle technique) Not Needed Access via thin-wall needle (confirmation of wire recommended) Ultrasound or ambiguous catheter or wire placement when using catheter-over-the-needle TEE technique Fluoroscopy ECG 13. Confirmation of Final Catheter in Venous System Prior to Use: Manometry Transducer 14. Final steps: Verify guidewire not retained Type and Dosage (ml / units) of Flush: _____________ Catheter Caps Placed on Lumens Tip position confirmation: Fluoroscopy Chest radiograph ordered Catheter Secured / Sutured in place 15. Transparent Bio-occlusive dressing applied 16. Sterile Technique Maintained when applying dressing 17. Dressing Dated 18. Confirm Final Location of Catheter Tip CXR Fluoroscopy Continuous ECG 19. After tip location confirmed, “Approved for use” Written on Dressing 20. Central line (maintenance) Order Placed Comments: Tip location:Anesthesiology 2012; 116:539 –73 552 Practice Guidelines
  15. 15. SPECIAL ARTICLESAppendix 4. Example Duties Performed by an Silver-impregnated catheters versus no coatingAssistant for Central Venous Catheterization Chlorhexidine combined with silver sulfadiazine catheter coating versus no coatingReads prompts on checklist to ensure that no safety Selection of catheter insertion site step is forgotten or missed. Completes checklist as Internal jugular task is completed SubclavianVerbally alerts anesthesiologist if a potential error or Femoral mistake is about to be made.Gathers equipment/supplies or brings standardized Selecting a potentially uncontaminated insertion site supply cart. Catheter fixationBrings the ultrasound machine, positions it, turns it on, Suture, staple, or tape makes adjustments as needed. Insertion site dressingsProvides moderate sedation (if registered nurse) if Clear plastic, chlorhexidine, gauze and tape, cyanoacrylate, needed. antimicrobial dressings, antibiotic ointmentParticipates in “time-out” before procedure. Catheter maintenanceWashes hands and wears mask, cap, and nonsterile Long-term versus short-term catheterization gloves (scrubs or cover gown required if in the sterile Frequency of insertion site inspection for signs of infection envelope). Changing cathetersAttends to patient requests if patient awake during procedure. Specified time intervalsAssists with patient positioning. Specified time interval versus no specified time interval (i.e., asAssists with draping. needed)Assists with sterile field setup; drops sterile items into One specified time interval versus another specified time interval field as needed. Changing a catheter over a wire versus a new siteAssists with sterile ultrasound sleeve application to Aseptic techniques using an existing central line for injection or ultrasound probe. aspirationAssists with attachment of intravenous lines or Wiping ports with alcohol pressure lines if needed. Capping stopcocksAssists with application of a sterile bandage at the end Needleless connectors or access ports of the procedure.Assists with clean-up of patient, equipment, and Prevention of Mechanical Trauma or Injury supply cart; returns items to their proper location. Selection of catheter insertion site Internal jugular SubclavianAppendix 5: Methods and Analyses FemoralState of the Literature Trendelenburg versus supine positionFor these Guidelines, a literature review was used in combination Needle insertion and catheter placementwith opinions obtained from expert consultants and other sources Selection of catheter type (e.g., double lumen, triple lumen,(e.g., ASA members, SPA members, open forums, Internet post- Cordis)ings). Both the literature review and opinion data were based on Selection of a large-bore catheterevidence linkages, or statements regarding potential relationships Placement of two catheters in the same veinbetween clinical interventions and outcomes. The interventions Use of a Seldinger technique versus a modified Seldingerlisted below were examined to assess their effect on a variety of techniqueoutcomes related to central venous catheterization. Limiting number of insertion attempts Resource Preparation Guidance of needle, wire and catheter placement Selection of a Sterile Environment Static ultrasound versus no ultrasound (i.e., anatomic Availability of a standardized equipment set landmarks) Use of a checklist or protocol for placement and maintenance Real-time ultrasound guidance versus no ultrasound Use of an assistant for placement Verification of placement Manometry versus direct pressure measurement (via pressure Prevention of Infectious Complications transducer) Intravenous antibiotic prophylaxis Continuous electrocardiogram Aseptic techniques Fluoroscopy Aseptic preparation Venous blood gas Hand washing, sterile full-body drapes, sterile gown, gloves, Transesophageal echocardiography mask, cap Chest radiography Skin preparation Chlorhexidine versus povidone-iodine Management of Trauma or Injury Arising from Central Venous Aseptic preparation with versus without alcohol Catheterization Selection of catheter coatings or impregnation Not removing versus removing central venous catheter on Antibiotic-coated catheters versus no coating evidence of arterial punctureAnesthesiology 2012; 116:539 –73 553 Practice Guidelines

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