Eliminating catheter-related bloodstream infections in the intensive care unit. Comparison of alcoholic chlorhexidine and povidoneiodine cutaneous antiseptics for the prevention of central venous catheter-related infection: A cohort and quasi-experimental multicenter study. Findings were then summarized for each evidence linkage and reported in the text of the updated Guideline, with summary evidence tables available as Supplemental Digital Content 4 (http://links.lww.com/ALN/C9). Survey Findings. Determine catheter insertion site selection based on clinical need and practitioner judgment, experience, and skill, Select an upper body insertion site when possible to minimize the risk of thrombotic complications relative to the femoral site, Perform central venous access in the neck or chest with the patient in the Trendelenburg position when clinically appropriate and feasible, Select catheter size (i.e., outside diameter) and type based on the clinical situation and skill/experience of the operator, Select the smallest size catheter appropriate for the clinical situation, For the subclavian approach select a thin-wall needle (i.e., Seldinger) technique versus a catheter-over-the-needle (i.e., modified Seldinger) technique, For the jugular or femoral approach, select a thin-wall needle or catheter-over-the-needle technique based on the clinical situation and the skill/experience of the operator, For accessing the vein before threading a dilator or large-bore catheter, base the decision to use a thin-wall needle technique or a catheter-over-the-needle technique at least in part on the method used to confirm that the wire resides in the vein (fig. Sustained reduction of central lineassociated bloodstream infections outside the intensive care unit with a multimodal intervention focusing on central line maintenance. Updated by the American Society of Anesthesiologists Task Force on Central Venous Access: Jeffrey L. Apfelbaum, M.D. Ultrasound evaluation of central veinsin the intensive care unit: Effects of dynamic manoeuvres. Chlorhexidine-impregnated sponges and less frequent dressing changes for prevention of catheter-related infections in critically ill adults: A randomized controlled trial. Netcare Antimicrobial Stewardship and Infection Prevention Study Alliance. Interventions intended to prevent infectious complications associated with central venous access include, but are not limited to, (1) intravenous antibiotic prophylaxis; (2) aseptic preparation of practitioner, staff, and patients; (3) selection of antiseptic solution; (4) selection of catheters containing antimicrobial agents; (5) selection of catheter insertion site; (6) catheter fixation method; (7) insertion site dressings; (8) catheter maintenance procedures; and (9) aseptic techniques using an existing central venous catheter for injection or aspiration. Advance the wire 20 to 30 cm. This line is placed into the vein that runs behind the collarbone. Literature Findings. For meta-analyses of antimicrobial, silver, or silver-sulfadiazine catheters studies reported actual event rates and odds ratios were pooled. They also may serve as a resource for other physicians (e.g., surgeons, radiologists), nurses, or healthcare providers who manage patients with central venous catheters. The procedure to place a femoral central line is as follows: You will have to lie down on your back for this procedure. (Committee Chair), Chicago, Illinois; Stephen M. Rupp, M.D. 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. Advance the guidewire through the needle and into the vein. The incidence of complications after the double-catheter technique for cannulation of the right internal jugular vein in a university teaching hospital. Survey Findings. Eliminating arterial injury during central venous catheterization using manometry. This may be done in your hospital room or an . A collaborative, systems-level approach to eliminating healthcare-associated MRSA, central-lineassociated bloodstream infections, ventilator-associated pneumonia, and respiratory virus infections. A prospective randomized trial of an antibiotic- and antiseptic-coated central venous catheter in the prevention of catheter-related infections. Prevention of catheter-related bloodstream infection in critically ill patients using a disinfectable, needle-free connector: A randomized controlled trial. The policy of the American Society of Anesthesiologists (ASA) Committee on Standards and Practice Parameters is to update practice guidelines every 5 yr. Catheter maintenance consists of (1) determining the optimal duration of catheterization, (2) conducting catheter site inspections, (3) periodically changing catheters, and (4) changing catheters using a guidewire instead of selecting a new insertion site. Copyright 2019, the American Society of Anesthesiologists, Inc. All Rights Reserved. A retrospective observational study reports that manometry can detect arterial punctures not identified by blood flow and color (Category B3-B evidence).213 The literature is insufficient to address ultrasound, pressure-waveform analysis, blood gas analysis, blood color, or the absence of pulsatile flow as effective methods of confirming catheter or thin-wall needle venous access. A prospective, randomized study in critically ill patients using the Oligon Vantex catheter. Anaphylactic shock induced by an antiseptic-coated central venous [correction of nervous] catheter. Ultrasound-guided supraclavicular central venous catheter tip positioning via the right subclavian vein using a microconvex probe. (Chair). The consultants and ASA members strongly agree with the recommendation to determine catheter insertion site selection based on clinical need and practitioner judgment, experience, and skill. Prepare the centralcatheter kit, and Level 3: The literature contains noncomparative observational studies with descriptive statistics (e.g., frequencies, percentages). The rate of return was 17.4% (n = 19 of 109). Iatrogenic arteriovenous fistula: A complication of percutaneous subclavian vein puncture. French Catheter Study Group in Intensive Care. Decreasing central lineassociated bloodstream infections through quality improvement initiative. Consultants were drawn from the following specialties where central venous access is a concern: anesthesiology (97% of respondents) and critical care (3% of respondents). Use of ultrasound to evaluate internal jugular vein anatomy and to facilitate central venous cannulation in paediatric patients. 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. Guidewire catheter change in central venous catheter biofilm formation in a burn population. Beyond the bundle: Journey of a tertiary care medical intensive care unit to zero central lineassociated bloodstream infections. Catheter-Related Infections in ICU (CRI-ICU) Group. Reduced rates of catheter-associated infection by use of a new silver-impregnated central venous catheter. Reduced colonization and infection with miconazole-rifampicin modified central venous catheters: A randomized controlled clinical trial. Location of the central venous catheter tip with bedside ultrasound in young children: Can we eliminate the need for chest radiography? Ultrasound localization of central vein catheter and detection of postprocedural pneumothorax: An alternative to chest radiography. Evolution and aetiological shift of catheter-related bloodstream infection in a whole institution: The microbiology department may act as a watchtower. Using the comprehensive unit-based safety program model for sustained reduction in hospital infections. Confirmation of endovenous placement of central catheter using the ultrasonographic bubble test., The use of ultrasound during and after central venous catheter insertion. The consultants and ASA members strongly agree with the recommendation to use real-time ultrasound guidance for vessel localization and venipuncture when the internal jugular vein is selected for cannulation. Literature Findings. Practice guidelines are systematically developed recommendations that assist the practitioner and patient in making decisions about health care. Reduction of central line infections in Veterans Administration intensive care units: An observational cohort using a central infrastructure to support learning and improvement. Meta-analyses of RCTs comparing real-time ultrasound-guided venipuncture of the internal jugular with an anatomical landmark approach report higher first insertion attempt success rates,186197 higher overall success rates,186,187,189192,194204 lower rates of arterial puncture,186188,190201,203,205 and fewer insertion attempts (Category A1-B evidence).188,190,191,194197,199,200,203205 RCTs also indicate reduced access time or times to cannulation with ultrasound compared with a landmark approach (Category A2-B evidence).188,191,194196,199,200,202205, For the subclavian vein, RCTs report fewer insertion attempts with real-time ultrasound-guided venipuncture (Category A2-B evidence),206,207 and higher overall success rates (Category A2-B evidence).206208 When compared with a landmark approach, findings are equivocal for arterial puncture207,208 and hematoma (Category A2-E evidence).207,208 For the femoral vein, an RCT reports a higher first-attempt success rate and fewer needle passes with real-time ultrasound-guided venipuncture compared with the landmark approach in pediatric patients (Category A3-B evidence).209, Meta-analyses of RCTs comparing static ultrasound with a landmark approach yields equivocal evidence for improved overall success for internal jugular insertion (Category A1-E evidence),190,202,210212 overall success irrespective of insertion site (Category A1-E evidence),182,190,202,210212 or impact on arterial puncture rates (Category A1-E evidence).190,202,210212 RCTs comparing static ultrasound with a landmark approach for locating the internal jugular vein report a higher first insertion attempt success rate with static ultrasound (Category A3-B evidence).190,212 The literature is equivocal regarding overall success for subclavian vein access (Category A3-E evidence)182 or femoral vein access when comparing static ultrasound to the landmark approach (Category A3-E evidence).202. Use real-time ultrasound guidance for vessel localization and venipuncture when the internal jugular vein is selected for cannulation (see fig. A significance level of P < 0.01 was applied for analyses. Impregnated central venous catheters for prevention of bloodstream infection in children (the CATCH trial): A randomised controlled trial. Validation of the concepts addressed by these guidelines and subsequent recommendations proposed was obtained by consensus from multiple sources, including: (1) survey opinion from consultants who were selected based on their knowledge or expertise in central venous access (2) survey opinions from a randomly selected sample of active members of the ASA; (3) testimony from attendees of publicly held open forums for the original guidelines at a national anesthesia meeting; and (4) internet commentary. Misplacement of a guidewire diagnosed by transesophageal echocardiography. Placement of a femoral line may be indicated in the following situations: to obtain vascular access when peripheral access cannot be accomplished, to administer hemodialysis when access at a. Always ensure target for venous cannulation is visualized and guidewire is placed correctly prior to dilation: 1) Compression of target vessel 2) Non-pulsatile dark blood return (unless on 100%FiO2, may be brighter red) 3) US visualization or needle and wire 4) can use pressure tubing and angiocath to confirm CVP or obtain venous O2 sat Reducing central lineassociated bloodstream infections in three ICUs at a tertiary care hospital in the United Arab Emirates. Ultrasound-guided central venous cannulation is superior to quick-look ultrasound and landmark methods among inexperienced operators: A prospective randomized study. document the position of the line. Literature exclusion criteria (except to obtain new citations): For the systematic review, potentially relevant clinical studies were identified via electronic and manual searches. Decreasing PICU catheter-associated bloodstream infections: NACHRIs quality transformation efforts. These seven evidence linkages are: (1) antimicrobial catheters, (2) silver impregnated catheters, (3) chlorhexidine and silver-sulfadiazine catheters, (4) dressings containing chlorhexidine, and (5) ultrasound guidance for venipuncture. Accepted for publication May 16, 2019. The consultants and ASA members strongly agree that for neonates, infants, and children, determine on a case-by-case basis whether to leave the catheter in place and obtain consultation or to remove the catheter nonsurgically. The effect of position and different manoeuvres on internal jugular vein diameter size. Survey Findings. Literature Findings. Use the subclavian site for central lines: Compared to the internal jugular or femoral sites, the subclavian site has a lower risk of thrombosis or line infection. Evidence categories refer specifically to the strength and quality of the research design of the studies. Efficacy of antiseptic-impregnated catheters on catheter colonization and catheter-related bloodstream infections in patients in an intensive care unit. Anesthesia was achieved using 1% lidocaine. The impact of a quality improvement intervention to reduce nosocomial infections in a PICU. Inadvertent prolonged cannulation of the carotid artery. Contamination of central venous catheters in immunocompromised patients: A comparison between two different types of central venous catheters. Supplemental Digital Content is available for this article. The journey to zero central catheter-associated bloodstream infections: Culture change in an intensive care unit. For neonates, infants, and children, confirmation of venous placement may take place after the wire is threaded. An evaluation with ultrasound. The variation between the two techniques reflects mitigation steps for the risk that the thin-wall needle in the Seldinger technique could move out of the vein and into the wall of an artery between the manometry step and the threading of the wire step. Survey Findings. In addition, practice guidelines developed by the American Society of Anesthesiologists (ASA) are not intended as standards or absolute requirements, and their use cannot guarantee any specific outcome. A multidisciplinary approach to reduce central lineassociated bloodstream infections. Do not force the wire; it should slide smoothly. Additional caution should be exercised in patients requiring femoral vein catheterization who have had prior arterial surgery. The authors declare no competing interests. In total, 4,491 unique new citations were identified, with 1,013 full articles assessed for eligibility. Evidence levels refer specifically to the strength and quality of the summarized study findings (i.e., statistical findings, type of data, and the number of studies reporting/replicating the findings). . The venous great vessels include the superior vena cava, inferior vena cava, brachiocephalic veins, internal jugular veins, subclavian veins, iliac veins, and common femoral veins. Excluded are catheters that terminate in a systemic artery. Simplified point-of-care ultrasound protocol to confirm central venous catheter placement: A prospective study. Randomized, controlled clinical trial of point-of-care limited ultrasonography assistance of central venous cannulation: The Third Sonography Outcomes Assessment Program (SOAP-3) Trial. Confirmation of venous placement for dialysis catheters should be done by venous blood gas prior to the initial dialysis run. The accuracy of electrocardiogram-controlled central line placement. 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. For these guidelines, central venous access is defined as placement of a catheter such that the catheter is inserted into a venous great vessel. Cardiac tamponade associated with a multilumen central venous catheter. Mark, M.D., Durham, North Carolina. Effects of varying entry points and trendelenburg positioning degrees in internal jugular vein area measurements of newborns. Internal jugular line. 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. trace the line from its insertion towards the heart. 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. The literature is insufficient to evaluate the efficacy of transparent bioocclusive dressings to reduce the risk of infection. Comparison of central venous catheterization with and without ultrasound guide. 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 consultants and ASA members agree that needleless catheter access ports may be used on a case-by-case basis, Do not routinely administer intravenous antibiotic prophylaxis, In preparation for the placement of central venous catheters, use aseptic techniques (e.g., hand washing) and maximal barrier precautions (e.g., sterile gowns, sterile gloves, caps, masks covering both mouth and nose, full-body patient drapes, and eye protection), Use a chlorhexidine-containing solution for skin preparation in adults, infants, and children, For neonates, determine the use of chlorhexidine-containing solutions for skin preparation based on clinical judgment and institutional protocol, If there is a contraindication to chlorhexidine, povidoneiodine or alcohol may be used, Unless contraindicated, use skin preparation solutions containing alcohol, For selected patients, use catheters coated with antibiotics, a combination of chlorhexidine and silver sulfadiazine, or silver-platinum-carbonimpregnated catheters based on risk of infection and anticipated duration of catheter use, Do not use catheters containing antimicrobial agents as a substitute for additional infection precautions, Determine catheter insertion site selection based on clinical need, Select an insertion site that is not contaminated or potentially contaminated (e.g., burned or infected skin, inguinal area, adjacent to tracheostomy or open surgical wound), In adults, select an upper body insertion site when possible to minimize the risk of infection, Determine the use of sutures, staples, or tape for catheter fixation on a local or institutional basis, Minimize the number of needle punctures of the skin, Use transparent bioocclusive dressings to protect the site of central venous catheter insertion from infection, Unless contraindicated, dressings containing chlorhexidine may be used in adults, infants, and children, For neonates, determine the use of transparent or sponge dressings containing chlorhexidine based on clinical judgment and institutional protocol, If a chlorhexidine-containing dressing is used, observe the site daily for signs of irritation, allergy, or necrosis, Determine the duration of catheterization based on clinical need, Assess the clinical need for keeping the catheter in place on a daily basis, Remove catheters promptly when no longer deemed clinically necessary, Inspect the catheter insertion site daily for signs of infection, Change or remove the catheter when catheter insertion site infection is suspected, When a catheter-related infection is suspected, a new insertion site may be used for catheter replacement rather than changing the catheter over a guidewire, Clean catheter access ports with an appropriate antiseptic (e.g., alcohol) before each access when using an existing central venous catheter for injection or aspiration, Cap central venous catheter stopcocks or access ports when not in use, Needleless catheter access ports may be used on a case-by-case basis. RCTs report equivocal findings for catheter tip colonization when catheters are changed at 3-day versus 7-day intervals (Category A2-E evidence).146,147 RCTs report equivocal findings for catheter tip colonization when guidewires are used to change catheters compared with new insertion sites (Category A2-E evidence).148150. Refer to appendix 2 for an example of a list of standardized equipment for adult patients. 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. Implementation of central venous catheter bundle in an intensive care unit in Kuwait: Effect on central lineassociated bloodstream infections. Central venous cannulation: Are routine chest radiographs necessary after B-mode and colour Doppler sonography check? Survey Findings. Preoperative chlorhexidine anaphylaxis in a patient scheduled for coronary artery bypass graft: A case report. Two observational studies indicate that ultrasound can confirm venous placement of the wire before dilation or final catheterization (Category B3-B evidence).214,215 Observational studies also demonstrate that transthoracic ultrasound can confirm residence of the guidewire in the venous system (Category B3-B evidence).216219 One observational study indicates that transesophageal echocardiography can be used to identify guidewire position (Category B3-B evidence),220 and case reports document similar findings (Category B4-B evidence).221,222, Observational studies indicate that transthoracic ultrasound can confirm correct catheter tip position (Category B2-B evidence).216,217,223240 Observational studies also indicate that fluoroscopy241,242 and chest radiography243,244 can identify the position of the catheter (Category B2-B evidence).
Positive And Negative Traits Of An Employee,
What Part Of Kentucky Gets The Least Tornadoes,
Gemini Lounge Haunted,
Articles H
