ASA Practice Guideline (2020) Recommendations:

Resource Preparation

  • Perform central venous catheterization in an environment that permits use of aseptic techniques

  • Ensure that a standardized equipment set is available for central venous access

  • Use a checklist or protocol for placement and maintenance of central venous catheters

  • Use an assistant during placement of a central venous catheter

Prevention of Infectious Complications

 

Intravenous Antibiotic Prophylaxis

  • Do not routinely administer intravenous antibiotic prophylaxis

Aseptic Preparation

  • 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)

Selection of Antiseptic Solution

  • 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, povidone–iodine or alcohol may be used

  • Unless contraindicated, use skin preparation solutions containing alcohol

Catheters Containing Antimicrobial Agents

  • For selected patients, use catheters coated with antibiotics, a combination of chlorhexidine and silver sulfadiazine, or silver-platinum-carbon–impregnated 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

Selection of Catheter Insertion Site

  • 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

Catheter Fixation

  • 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

Insertion Site Dressings

  • 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

Catheter Maintenance

  • 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

Aseptic Techniques Using an Existing Central Venous Catheter for Injection or Aspiration

  • 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

Prevention of Mechanical Trauma or Injury

 

Catheter Insertion Site Selection

  • 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

Positioning the Patient for Needle Insertion and Catheter Placement

  • Perform central venous access in the neck or chest with the patient in the Trendelenburg position when clinically appropriate and feasible

Needle Insertion, Wire Placement, and Catheter Placement

  • 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.

  • 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

Guidance of Needle, Wire, and Catheter Placement

  • Use real-time ultrasound guidance for vessel localization and venipuncture when the internal jugular vein is selected for cannulation

    • When feasible, real-time ultrasound may be used when the subclavian or femoral vein is selected

  • Use static ultrasound imaging before prepping and draping for prepuncture identification of anatomy to determine vessel localization and patency when the internal jugular vein is selected for cannulation

    • Static ultrasound may also be used when the subclavian or femoral vein is selected

Verification of Needle, Wire, and Catheter Placement

  • After insertion of a catheter that went over the needle or a thin-wall needle, confirm venous access

    • Do not rely on blood color or absence of pulsatile flow for confirming that the catheter or thin-wall needle resides in the vein

  • When using the thin-wall needle technique, confirm venous residence of the wire after the wire is threaded

    • When using the catheter-over-the-needle technique, confirmation that the wire resides in the vein may not be needed (1) when the catheter enters the vein easily and manometry or pressure-waveform measurement provides unambiguous confirmation of venous location of the catheter and (2) when the wire passes through the catheter and enters the vein without difficulty

    • If there is any uncertainty that the catheter or wire resides in the vein, confirm venous residence of the wire after the wire is threaded; insertion of a dilator or large-bore catheter may then proceed

  • After final catheterization and before use, confirm residence of the catheter in the venous system as soon as clinically appropriate

  • Confirm the final position of the catheter tip as soon as clinically appropriate

    • For central venous catheters placed in the operating room, perform a chest radiograph no later than the early postoperative period to confirm the position of the catheter tip

  • Verify that the wire has not been retained in the vascular system at the end of the procedure by confirming the presence of the removed wire in the procedural field

    • If the complete guidewire is not found in the procedural field, order chest radiography to determine whether the guidewire has been retained in the patient’s vascular system

Management of Arterial Trauma or Injury Arising from Central Venous Catheterization

  • When unintended cannulation of an arterial vessel with a dilator or large-bore catheter occurs, leave the dilator or catheter in place and immediately consult a general surgeon, a vascular surgeon, or an interventional radiologist regarding surgical or nonsurgical catheter removal for adults

  • 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

  • After the injury has been evaluated and a treatment plan has been executed, confer with the surgeon regarding relative risks and benefits of proceeding with the elective surgery versus deferring surgery to allow for a period of patient observation

Reference:

  1. Practice Guidelines for Central Venous Access 2020An Updated Report by the American Society of Anesthesiologists Task Force on Central Venous Access. Anesthesiology January 2020.

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