Kolb's Experiential Learning Cycle Strengths And Weaknesses, Articles H

The consultants and ASA members both strongly agree with the recommendations to use transparent bioocclusive dressings to protect the site of central venous catheter insertion from infection. Conflict-of-interest documentation regarding current or potential financial and other interests pertinent to the practice guideline were disclosed by all task force members and managed. Refer to appendix 3 for an example of a checklist or protocol. 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. Reduction of central line infections in Veterans Administration intensive care units: An observational cohort using a central infrastructure to support learning and improvement. The percentage of responding consultants expecting no change associated with each linkage were as follows: (1) resource preparation (environment with aseptic techniques, standardized equipment set) = 89.5%; (2) use of a trained assistant = 100%; (3) use of a checklist or protocol for placement and maintenance = 89.5%; (4) aseptic preparation (hand washing, sterile full-body drapes, etc.) Power analysis for random-effects meta-analysis. Metasens: Advanced Statistical Methods to Model and Adjust for Bias in Meta-Analysis. **, Comparative studies are insufficient to evaluate the efficacy of chlorhexidine and alcohol compared with chlorhexidine without alcohol for skin preparation during central venous catheterization. The evidence model below guided the search, providing inclusion and exclusion information regarding patients, procedures, practice settings, providers, clinical interventions, and outcomes. A prospective randomized trial of an antibiotic- and antiseptic-coated central venous catheter in the prevention of catheter-related infections. When available, category A evidence is given precedence over category B evidence for any particular outcome. Eliminating catheter-related bloodstream infections in the intensive care unit. The purposes of these guidelines are to (1) provide guidance regarding placement and management of central venous catheters; (2) reduce infectious, mechanical, thrombotic, and other adverse outcomes associated with central venous catheterization; and (3) improve management of arterial trauma or injury arising from central venous catheterization. The consultants strongly agree and ASA members agree with the recommendation to use a checklist or protocol for placement and maintenance of central venous catheters. Catheter-associated bloodstream infection in the pediatric intensive care unit: A multidisciplinary approach. The Central Venous Catheter-Related Infections Study Group. 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. Accepted for publication May 16, 2019. 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 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. These studies were combined with 258 pre-2011 articles from the previous guidelines, resulting in a total of 542 articles accepted as evidence for these guidelines. Survey Findings. The rate of return was 17.4% (n = 19 of 109). Chlorhexidine-impregnated dressing for prevention of colonization of central venous catheters in infants and children: A randomized controlled study. The consultants and ASA members strongly agree with the following recommendations: (1) after final catheterization and before use, confirm residence of the catheter in the venous system as soon as clinically appropriate; (2) confirm the final position of the catheter tip as soon as clinically appropriate; (3) 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; (4) 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; and (5) 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. This line is placed into the vein that runs behind the collarbone. Proper maintenance of CVCs includes disinfection of catheter hubs, connectors, and injection ports and changing dressings over the site every two days for gauze . The guidelines do not address (1) clinical indications for placement of central venous catheters; (2) emergency placement of central venous catheters; (3) patients with peripherally inserted central catheters; (4) placement and residence of a pulmonary artery catheter; (5) insertion of tunneled central lines (e.g., permacaths, portacaths, Hickman, Quinton); (6) methods of detection or treatment of infectious complications associated with central venous catheterization; (7) removal of central venous catheters; (8) diagnosis and management of central venous catheter-associated trauma or injury (e.g., pneumothorax or air embolism), with the exception of carotid arterial injury; (9) management of periinsertion coagulopathy; and (10) competency assessment for central line insertion. A 20-year retained guidewire: Should it be removed? 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. The central line is placed in your body during a brief procedure. There are many uses of these catheters. An observational study reports that implementation of a trauma intensive care unit multidisciplinary checklist is associated with reduced catheter-related infection rates (Category B2-B evidence).6 Observational studies report that central lineassociated or catheter-related bloodstream infection rates are reduced when intensive care unit-wide bundled protocols are implemented736(Category B2-B evidence); evidence from fewer observational studies is equivocal3755(Category B2-E evidence); other observational studies5671 do not report levels of statistical significance or lacked sufficient data to calculate them. Positioning the tip of a central venous catheter (CVC) within the superior vena cava (SVC) at or just above the level of the carina is generally considered acceptable for most short-term uses, such as fluid administration or monitoring of central venous pressure. Using the comprehensive unit-based safety program model for sustained reduction in hospital infections. Real-time ultrasound-guided catheterisation of the internal jugular vein: A prospective comparison with the landmark technique in critical care patients. Advance the guidewire through the needle and into the vein. Accepted studies from the previous guidelines were also rereviewed, covering the period of January 1, 1971, through June 31, 2011. American Society of Anesthesiologists Task Force on Central Venous A. . 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. The ASA Committee on Standards and Practice Parameters reviews all practice guidelines at the ASA annual meeting and determines update and revision timelines. Ultrasound-guided supraclavicular central venous catheter tip positioning via the right subclavian vein using a microconvex probe. Transthoracic echocardiographic guidance for obtaining an optimal insertion length of internal jugular venous catheters in infants. Comparison of Oligon catheters and chlorhexidine-impregnated sponges with standard multilumen central venous catheters for prevention of associated colonization and infections in intensive care unit patients: A multicenter, randomized, controlled study. Category B: Observational studies or RCTs without pertinent comparison groups may permit inference of beneficial or harmful relationships among clinical interventions and clinical outcomes. The small . Use real-time ultrasound guidance for vessel localization and venipuncture when the internal jugular vein is selected for cannulation (see fig. Methods for confirming that the catheter or thin-wall needle resides in the vein include, but are not limited to, ultrasound, manometry, or pressure-waveform analysis measurement. Antiseptic-bonded central venous catheters and bacterial colonisation. Central venous line sepsis in the intensive care unit: A study comparing antibiotic coated catheters with plain catheters. An unexpected image on a chest radiograph. The literature is insufficient to evaluate whether cleaning ports or capping stopcocks when using an existing central venous catheter for injection or aspiration decreases the risk of catheter-related infections. Decreasing central lineassociated bloodstream infections through quality improvement initiative. Refer to appendix 2 for an example of a list of standardized equipment for adult patients. The epidemiology, antibiograms and predictors of mortality among critically-ill patients with central lineassociated bloodstream infections. Chlorhexidine-related refractory anaphylactic shock: A case successfully resuscitated with extracorporeal membrane oxygenation. No respondents indicated that new equipment, supplies, or training would not be needed to implement the guidelines, and 88.9% indicated that implementation of the guidelines would not require changes in practice that would affect costs. Impregnated central venous catheters for prevention of bloodstream infection in children (the CATCH trial): A randomised controlled trial. Prevention of catheter-related infections by silver coated central venous catheters in oncological patients. Catheter infection risk related to the distance between insertion site and burned area. Citation searching (backward and forward) of relevant meta-analyses and other systematic reviews was also performed; pre-2011 studies relevant to meta-analyses or use of ultrasound were eligible for inclusion. The results of the surveys are reported in tables 2 and 3 and are summarized in the text of the guidelines.#####, American Society of Anesthesiologists Member Survey Results. 1), After insertion of a catheter that went over the needle or a thin-wall needle, confirm venous access, If there is any uncertainty that the catheter or wire resides in the vein, confirm venous residence of the wire after the wire is threaded; insertion of a dilator or large-bore catheter may then proceed, After final catheterization and before use, confirm residence of the catheter in the venous system as soon as clinically appropriate####, Confirm the final position of the catheter tip as soon as clinically appropriate*****, Example of a Standardized Equipment Cart for Central Venous Catheterization for Adult Patients. Risk factors of failure and immediate complication of subclavian vein catheterization in critically ill patients. RCTs comparing subclavian and femoral insertion sites report higher rates of catheter colonization at the femoral site (Category A2-H evidence); findings for catheter-related sepsis or catheter-related bloodstream infection are equivocal (Category A2-E evidence).130,131 An RCT finds a higher rate of catheter colonization for internal jugular compared with subclavian insertion (Category A3-H evidence) and for femoral compared with internal jugular insertion (Category A3-H evidence); evidence is equivocal for catheter-related bloodstream infection for either comparison (Category A3-E evidence).131 A nonrandomized comparative study of burn patients reports that catheter colonization and catheter-related bloodstream infection occur more frequently with an insertion site closer to the burn location (Category B1-H evidence).132. Arterial blood was withdrawn. Ultrasound guidance outcomes were pooled using risk or mean differences (continuous outcomes) for clinical relevance. Allergy to chlorhexidine: Beware of the central venous catheter. Internal jugular line. For membership respondents, the survey rate of return was 8% (n = 393 of 5,000) members. RCTs comparing continuous electrocardiographic guidance for catheter placement with no electrocardiography indicate that continuous electrocardiography is more effective in identifying proper catheter tip placement (Category A2-B evidence).245247 Case reports document unrecognized retained guidewires resulting in complications including embolization and fragmentation,248 infection,249 arrhythmia,250 cardiac perforation,248 stroke,251 and migration through soft-tissue (Category B-4H evidence).252. Femoral vein cannulation performed by residents: A comparison between ultrasound-guided and landmark technique in infants and children undergoing cardiac surgery. Effect of a second-generation venous catheter impregnated with chlorhexidine and silver sulfadiazine on central catheter-related infections: A randomized, controlled trial. subclavian vein (left or right) assessing position. The consultants and ASA members strongly agree with the recommendation to select catheter size (i.e., outside diameter) and type based on the clinical situation and skill/experience of the operator. The literature is insufficient to evaluate outcomes associated with the routine use of intravenous prophylactic antibiotics. Statewide NICU central-lineassociated bloodstream infection rates decline after bundles and checklists. A multicentre analysis of catheter-related infection based on a hierarchical model. 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. R: A Language and Environment for Statistical Computing. window the image to best visualize the line. Although observational studies report that Trendelenburg positioning (i.e., head down from supine) increases the right internal jugular vein diameter or cross-sectional area in adult volunteers (Category B2-B evidence),157161 findings are equivocal for studies enrolling adult patients (Category B2-E evidence).158,162164 Observational studies comparing the Trendelenburg position and supine position in pediatric patients report increased right internal jugular vein diameter or cross-sectional area (Category B2-B evidence),165167 and one observational study of newborns reported similar findings (Category B2-B evidence).168 The literature is insufficient to evaluate whether Trendelenburg positioning improves insertion success rates or decreases the risk of mechanical complications. Opinion surveys were developed by the task force to address each clinical intervention identified in the document. Practice guidelines are subject to revision as warranted by the evolution of medical knowledge, technology, and practice. Advance the wire 20 to 30 cm. A multitiered strategy of simulation training, kit consolidation, and electronic documentation is associated with a reduction in central lineassociated bloodstream infections. The authors declare no competing interests. Assessment of conceptual issues, practicality, and feasibility of the guideline recommendations was also evaluated, with opinion data collected from surveys and other sources. Survey Findings. Central lineassociated bloodstream infection in a trauma intensive care unit: Impact of implementation of Society for Healthcare Epidemiology of America/Infectious Diseases Society of America practice guidelines. The SiteRite ultrasound machine: An aid to internal jugular vein cannulation. Interventions intended to prevent mechanical trauma or injury associated with central venous access include but are not limited to (1) selection of catheter insertion site; (2) positioning the patient for needle insertion and catheter placement; (3) needle insertion, wire placement, and catheter placement; (4) guidance for needle, guidewire, and catheter placement, and (5) verification of needle, wire, and catheter placement. In this document, 249 are referenced, with a complete bibliography of articles used to develop these guidelines, organized by section, available as Supplemental Digital Content 3 (http://links.lww.com/ALN/C8). How useful is ultrasound guidance for internal jugular venous access in children? Double-lumen central venous catheters impregnated with chlorhexidine and silver sulfadiazine to prevent catheter colonisation in the intensive care unit setting: A prospective randomised study. Evolution and aetiological shift of catheter-related bloodstream infection in a whole institution: The microbiology department may act as a watchtower. Reduction of catheter-related bloodstream infections through the use of a central venous line bundle: Epidemiologic and economic consequences. The subclavian veins are an often favored site for central venous access, including emergency and acute care access, and tunneled catheters and subcutaneous ports for chemotherapy, prolonged antimicrobial therapy, and parenteral . Level 2: The literature contains noncomparative observational studies with associative statistics (e.g., correlation, sensitivity, and specificity). Is a routine chest x-ray necessary for children after fluoroscopically assisted central venous access? Comparison of central venous catheterization with and without ultrasound guide. Survey findings from task forceappointed expert consultants and a random sample of the ASA membership are fully reported in the text of these guidelines. The consultants and ASA members strongly agree with the recommendation to confirm venous residence of the wire after the wire is threaded if there is any uncertainty that the catheter or wire resides in the vein, and insertion of a dilator or large-bore catheter may then proceed. Survey Findings. Anaphylaxis to chlorhexidine-coated central venous catheters: A case series and review of the literature. The consultants and ASA members agree with the recommendation to use an assistant during placement of a central venous catheter. This is a particular concern during peripheral insertion or insertion of catheters via the axillary vein or subclavian vein, when ultrasound scanning of the internal jugular vein may rule out a 'wrong' upward direction of the catheter or wire. tient's leg away from midline. Verification of needle, wire, and catheter placement includes (1) confirming that the catheter or thin-wall needle resides in the vein, (2) confirming venous residence of the wire, and (3) confirming residence of the catheter in the venous system and final catheter tip position.. Confirmation of correct central venous catheter position in the preoperative setting by echocardiographic bubble-test.. ), 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). Saline flush test: Can bedside sonography replace conventional radiography for confirmation of above-the-diaphragm central venous catheter placement? These updated guidelines were developed by means of a five-step process. Antimicrobial durability and rare ultrastructural colonization of indwelling central catheters coated with minocycline and rifampin. Placing the central line. Evidence was obtained from two principal sources: scientific evidence and opinion-based evidence. Prevention of central venous catheter related infections with chlorhexidine gluconate impregnated wound dressings: A randomized controlled trial. Anaphylaxis to chlorhexidine in a chlorhexidine-coated central venous catheter during general anaesthesia. Reduced colonization and infection with miconazole-rifampicin modified central venous catheters: A randomized controlled clinical trial. The consultants and ASA members strongly agree with the recommendation to use aseptic techniques (e.g., hand washing) and maximal barrier precautions (e.g., sterile gowns, sterile gloves, caps, masks covering both mouth and nose, and full-body patient drapes) in preparation for the placement of central venous catheters.