Practice Guidelines for Central Venous Access

PRACTICE Guidelines are systematically developed recommendations that assist the practitioner and patient in making decisions about health care. These recommendations may be adopted, modified, or rejected according to clinical needs and constraints, and are not intended to replace local institutional policies. 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. Practice Guidelines are subject to revision as warranted by the evolution of medical knowledge, technology, and practice. They provide basic recommendations that are supported by a synthesis and analysis of the current literature, expert and practitioner opinion, open forum commentary, and clinical feasibility data.For these Guidelines, central venous access is defined as placement of a catheter such that the catheter is inserted into a venous great vessel. 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.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.These Guidelines apply to patients undergoing elective central venous access procedures performed by anesthesiologists or health care professionals under the direction/supervision of anesthesiologists. 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, or (7) diagnosis and management of central venous catheter-associated trauma or injury (e.g. , pneumothorax or air embolism), with the exception of carotid arterial injury.These Guidelines are intended for use by anesthesiologists and individuals who are under the supervision of an anesthesiologist. They also may serve as a resource for other physicians (e.g. , surgeons, radiologists), nurses, or health care providers who manage patients with central venous catheters.The ASA appointed a Task Force of 12 members, including anesthesiologists in both private and academic practice from various geographic areas of the United States and two consulting methodologists from the ASA Committee on Standards and Practice Parameters.The Task Force developed the Guidelines by means of a seven-step process. First, they reached consensus on the criteria for evidence. Second, original published research studies from peer-reviewed journals relevant to central venous access were reviewed and evaluated. Third, expert consultants were asked to (1) participate in opinion surveys on the effectiveness of various central venous access recommendations and (2) review and comment on a draft of the Guidelines. Fourth, opinions about the Guideline recommendations were solicited from a sample of active members of the ASA. Opinions on selected topics related to pediatric patients were solicited from a sample of active members of the Society for Pediatric Anesthesia (SPA). Fifth, the Task Force held open forums at three major national meetings†to solicit input on its draft recommendations. Sixth, the consultants were surveyed to assess their opinions on the feasibility of implementing the Guidelines. Seventh, all available information was used to build consensus within the Task Force to finalize the Guidelines. A summary of recommendations may be found in appendix 1.Preparation of these Guidelines followed a rigorous methodologic process. Evidence was obtained from two principal sources: scientific evidence and opinion-based evidence.Study findings from published scientific literature were aggregated and are reported in summary form by evidence category, as described in the following paragraphs. All literature (e.g. , randomized controlled trials, observational studies, case reports) relevant to each topic was considered when evaluating the findings. However, for reporting purposes in this document, only the highest level of evidence (i.e. , level 1, 2, or 3 within category A, B, or C, as identified in the following paragraphs) is included in the summary.Randomized controlled trials report statistically significant (P < 0.01) differences between clinical interventions for a specified clinical outcome.Information from observational studies permits inference of beneficial or harmful relationships among clinical interventions and clinical outcomes.The literature cannot determine whether there are beneficial or harmful relationships among clinical interventions and clinical outcomes.The lack of scientific evidence in the literature is described by the following terms: All opinion-based evidence relevant to each topic (e.g. , survey data, open-forum testimony, Internet-based comments, letters, editorials) is considered in the development of these Guidelines. However, only the findings obtained from formal surveys are reported.Opinion surveys were developed by the Task Force to address each clinical intervention identified in the document. Identical surveys were distributed to expert consultants and ASA members, and a survey addressing selected pediatric issues was distributed to SPA members.Survey responses from Task Force-appointed expert consultants are reported in summary form in the text, with a complete listing of consultant survey responses reported in appendix 5.Survey responses from active ASA and SPA members are reported in summary form in the text, with a complete listing of ASA and SPA member survey responses reported in appendix 5.Survey responses are recorded using a 5-point scale and summarized based on median values.§Open-forum testimony, Internet-based comments, letters, and editorials are all informally evaluated and discussed during the development of Guideline recommendations. When warranted, the Task Force may add educational information or cautionary notes based on this information.Resource preparation includes (1) assessing the physical environment where central venous catheterization is planned to determine the feasibility of using aseptic techniques, (2) availability of a standardized equipment set, (3) use of an assistant for central venous catheterization, and (4) use of a checklist or protocol for central venous catheter placement and maintenance.The literature is insufficient to specifically 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 (Category D evidence ). An observational study reports that the implementation of a trauma intensive care unit multidisciplinary checklist is associated with reduced catheter-related infection rates (Category B2 evidence ).1Observational studies report reduced catheter-related bloodstream infection rates when intensive care unit-wide bundled protocols are implemented (Category B2 evidence ).2–7These studies do not permit the assessment of the effect of any single component of a checklist or bundled protocol on outcome. The Task Force notes that the use of checklists in other specialties or professions has been effective in reducing the error rate for a complex series of activities.8,9The consultants and ASA members strongly agree that central venous catheterization should be performed in a location that permits the use of aseptic techniques. The consultants and ASA members strongly agree that a standardized equipment set should be available for central venous access. The consultants and ASA members agree that a trained assistant should be used during the placement of a central venous catheter. The ASA members agree and the consultants strongly agree that a checklist or protocol should be used for the placement and maintenance of central venous catheters.Central venous catheterization should be performed in an environment that permits use of aseptic techniques. A standardized equipment set should be available for central venous access.‖A checklist or protocol should be used for placement and maintenance of central venous catheters.#An assistant should be used during placement of a central venous catheter.**Interventions intended to prevent infectious complications associated with central venous access include, but are not limited to (1) intravenous antibiotic prophylaxis, (2) aseptic techniques (i.e. , practitioner aseptic preparation and patient skin preparation), (3) selection of coated or impregnated catheters, (4) selection of catheter insertion site, (5) catheter fixation method, (6) insertion site dressings, (7) catheter maintenance procedures, and (8) aseptic techniques using an existing central venous catheter for injection or aspiration.Randomized controlled trials indicate that catheter-related infections and sepsis are reduced when prophylactic intravenous antibiotics are administered to high-risk immunosuppressed cancer patients or neonates (Category A2 evidence ).10,11The literature is insufficient to evaluate outcomes associated with the routine use of intravenous antibiotics (Category D evidence ).The consultants and ASA members agree that intravenous antibiotic prophylaxis may be administered on a case-by-case basis for immunocompromised patients or high-risk The consultants and ASA members agree that intravenous antibiotic prophylaxis should not be administered immunocompromised patients and high-risk intravenous antibiotic prophylaxis on a case-by-case antibiotic prophylaxis should not be administered preparation of and A randomized controlled (i.e. , with a (i.e. , and reported findings for reduced (P and catheter-related (P (Category evidence literature is insufficient to evaluate the of specific aseptic (e.g. , or (e.g. , (Category D evidence ). studies report and as of care that in reduced catheter-related bloodstream infections (Category B2 evidence the to each to outcomes not be consultants and ASA members that the following aseptic techniques should be used in preparation for the placement of central venous and and and and and and both the and and A randomized controlled with for skin preparation reports findings regarding catheter (P and catheter-related (P (Category evidence literature is insufficient to evaluate with with with (Category D evidence ). The literature is insufficient to evaluate the of in and (Category D evidence studies are insufficient to evaluate the of with in with for skin preparation during central venous catheterization (Category D evidence ). A randomized controlled of with that catheter is reduced when with (Category evidence findings are reported for catheter-related infection (P and clinical of infection (P (Category evidence consultants and ASA members strongly agree that with should be used for skin SPA members are regarding whether should be used for skin preparation in neonates they agree with the use of in and strongly agree with its use in preparation for the placement of central venous catheters, use aseptic techniques (e.g. , and (e.g. , both and and patient A should be used for skin preparation in and for the use of a for skin preparation should be based on clinical and institutional there is a to or may be skin preparation should of randomized controlled with catheters that catheters reduce catheter (Category evidence ). of randomized controlled catheters with catheters report findings for catheter-related bloodstream infection (Category evidence randomized controlled trials were regarding catheter (P (Category evidence of randomized controlled that catheters coated with and reduce catheter (Category evidence findings are reported for catheter-related bloodstream infection (i.e. , catheter and (Category evidence of are reported placement of a catheter coated with and (Category evidence and ASA members agree that catheters coated with antibiotics or a of and may be used in selected patients based on infectious and of catheter coated with antibiotics or a of and should be used for selected patients based on infectious and of catheter The Task Force notes that catheters are not a for infection randomized controlled the subclavian and femoral insertion report of catheter with the femoral site (Category evidence findings are reported for catheter-related sepsis (P (Category evidence randomized controlled the internal jugular insertion site with the femoral site reports in catheter (P or catheter related bloodstream infections (P (Category evidence studies are (i.e. , regarding catheter-related catheter related bloodstream the internal jugular site is with the subclavian site (Category evidence ). A study of patients reports that catheter and the the catheter insertion site is to the (Category evidence consultants indicate that the subclavian insertion site is to catheter-related of ASA members indicate that the internal jugular insertion site is to catheter-related of The consultants and ASA members agree that femoral catheterization should be when to the of The consultants and ASA members strongly agree that an insertion site should be selected that is not or insertion site selection should be based on clinical An insertion site should be selected that is not or (e.g. , or to or open In selection of an insertion site should be considered to the of literature is insufficient to evaluate whether catheter fixation with or is associated with a for catheter-related infections (Category D evidence consultants and ASA members indicate that use of is the catheter fixation to catheter-related use of or for catheter fixation should be on a local or institutional literature is insufficient to evaluate the of to reduce the of infection (Category D evidence ). controlled trials are (P regarding catheter (P regarding catheter-related bloodstream are with (Category evidence ). A randomized controlled is also regarding catheter for with (P (Category evidence randomized controlled reports a of when neonates with impregnated (Category evidence ASA members agree and the consultants strongly agree that should be used to the site of central venous catheter insertion from The consultants and ASA members agree that may be used to reduce the of catheter-related SPA members are regarding whether may be used for skin preparation in neonates they agree that the use of may be used in and should be used to the site of central venous catheter insertion from may be used in and the use of or should be based on clinical and institutional maintenance of (1) the of catheterization, (2) catheter site (3) catheters, and (4) catheters using a of a insertion studies indicate that are associated with rates of catheter and sepsis (Category B2 evidence literature is insufficient to evaluate whether specified between catheter site are associated with a for catheter-related infection (Category D evidence ). controlled trials report findings (P regarding differences in catheter when catheters are at (Category evidence of randomized controlled findings for catheter when are used to catheters with the use of insertion (Category evidence ).The ASA members agree and the consultants strongly agree that the of catheterization should be based on clinical The consultants and ASA members strongly agree that (1) the clinical for the catheter in should be (2) catheters should be when (3) the catheter site should be for of infection and when infection is and (4) when catheter infection is the catheter using a insertion site is to the catheter a of catheterization should be based on clinical The clinical for the catheter in should be should be when The catheter insertion site should be for of and the catheter should be or when catheter insertion site infection is When a catheter related infection is the catheter using a insertion site is to the catheter a techniques using an existing central venous catheter for injection or of (1) the with an (2) or access and (3) use of catheter or access literature is insufficient to evaluate whether or when using an existing central venous catheter for injection or is associated with a reduced for catheter-related infections (Category D evidence ). controlled trials with indicate of of with (Category A2 evidence differences in catheter-related bloodstream infection are reported (P (Category evidence consultants and ASA members strongly agree that catheter access should be with an each access. The consultants and ASA members agree that may be used on a case-by-case The consultants and ASA members strongly agree that central venous catheter should be when not in access should be with an each access when using an existing central venous catheter for injection or venous catheter or access should be when not in catheter access may be used on a case-by-case intended to prevent trauma or injury associated with central venous access include, but are not limited to (1) selection of catheter insertion site, (2) the patient for insertion and catheter (3) insertion and catheter and (4) for and catheter randomized controlled the subclavian and femoral insertion reports that the femoral site a of complications in patients (Category evidence randomized controlled the internal jugular insertion site with the femoral site reports findings for arterial (P venous (P or (P (Category evidence randomized controlled the internal jugular insertion site with the subclavian site reports findings for (P (Category evidence studies report findings for arterial or when the internal jugular insertion site is with the subclavian insertion site (Category evidence consultants and ASA members indicate that the internal jugular insertion site is to catheter of injury or consultants and ASA members also indicate that the internal jugular insertion site is to catheter-related of injury or insertion site selection should be based on clinical and practitioner and In selection of an insertion site should be considered to the of studies the (i.e. , with the that the internal jugular in and to a when patients are in the (Category B2 evidence study the with the in pediatric patients reports an in internal jugular only for patients (Category B2 evidence consultants and ASA members strongly agree when and central access in the or should be performed with the patient in the and central venous access in the or should be performed with the patient in the insertion, and catheter placement includes (1) selection of catheter and (2) use of a (i.e. , a (i.e. , (3) the of insertion and (4) two catheters in the central reports injury (e.g. , arterial injury including and or when there is arterial with catheters (Category evidence literature is insufficient to evaluate whether the of injury or trauma is associated with the use of a a (Category D evidence ). The literature is insufficient to evaluate whether the of injury or trauma is related to the of insertion (Category D evidence ). study reports a of when two central venous catheters are in the internal with placement of catheter in the (Category B2 evidence differences in carotid artery (P or (P were (Category evidence consultants agree and the ASA members strongly agree that the selection of catheter (i.e. , of and (e.g. , should be based on the clinical and the and of the The consultants and ASA members agree that the selection of a a should be based on the clinical and the and of the The consultants and ASA members agree that the of insertion should be based on clinical The ASA members agree and the consultants strongly agree that the to two central catheters in a single should be on a case-by-case of catheter (i.e. , and should be based on the clinical and of the of the catheter for the clinical should be of a (i.e. , a (i.e. , should be based on the clinical and the of the The to use a or a should be based at in on the used to that the in the a or catheter is The Task Force notes that the may provide venous access is used for venous The of insertion should be based on clinical The to two catheters in a single should be on a case-by-case for and catheter placement includes for the of (i.e. , and for and the to its intended venous location (i.e. , or of or catheter location includes any or of the following (1) (2) (3) (4) venous (5) (6) (7) and (8) controlled trials with the for the internal jugular report a insertion rate for (Category evidence are regarding rates (P (Category evidence addition, the literature is regarding subclavian access (P (Category evidence insufficient for femoral access (Category D evidence ).The consultants and ASA members agree that should be used in elective for of and when the internal jugular is selected for they are regarding whether should be used when the subclavian is The consultants agree and the ASA members are regarding the use of when the femoral is of randomized controlled with the of the internal jugular has a insertion reduced access and rates of arterial (Category evidence ). controlled trials report of insertion with of the internal jugular (Category A2 evidence the subclavian randomized controlled trials report insertion with (Category A2 evidence randomized clinical a rate and reduced access with arterial and with the (Category evidence the femoral a randomized controlled reports a rate and with with the in pediatric patients (Category evidence consultants agree and the ASA members are when should be used for guidance during venous access when the internal jugular or femoral are selected for The consultants and ASA members are regarding the use of when the subclavian is observational study reports that arterial not identified by and (Category B2 evidence literature is insufficient to address or the of as effective methods of catheter or venous access (Category D evidence observational study that be used to venous placement of the or catheterization (Category B2 evidence reports indicate that was used to (Category evidence literature is insufficient to evaluate the of in venous residence of the (Category D evidence complex is by the Task Force as an of venous location of the The literature is insufficient to address as an effective to venous residence of the (Category D evidence the Task Force that may be with observational findings indicate that in the of the catheter (Category B2 evidence ). controlled trials indicate that is effective in catheter placement with not using (Category A2 evidence consultants and ASA members strongly agree that insertion of a or catheter a venous access should be for the catheter or that the The Task Force that or of should not be to venous access. The consultants agree and ASA members are that venous access should be for the that in the a catheter or insertion of a or catheter a The consultants and ASA members agree when both the location of the catheter or and should be consultants and ASA members agree that a should be performed to the location of the catheter as catheterization as They also agree for central venous catheters in the a may be performed in the The ASA members agree and the consultants strongly agree a is to the or should be used to venous of the catheter following are for of trauma during and catheter placement in elective reports of patients with arterial by a during central venous catheterization indicate complications (e.g. , catheter such complications were reported for patients catheters were in and (Category evidence consultants and ASA members agree when of an arterial with a catheter the catheter should be in and a or should be When of an arterial with a catheter the SPA members indicate that the catheter should be in and a or should be on whether to the catheter, or as and SPA members that the catheter may be is as and The Task Force that the and should regarding the and of with elective an arterial has injury by a or of an arterial with a or catheter the or catheter should be in and a a or an should be regarding or catheter for and the to the catheter in and or to the catheter should be based on practitioner and the injury has been evaluated and a treatment has been the and should regarding and of with the elective to for a of patient these Guidelines, a literature review was used in with opinions obtained from expert consultants and other (e.g. , ASA members, SPA members, open the literature review and opinion were based on evidence or regarding relationships between clinical interventions and The interventions were to assess their effect on a of outcomes related to central venous of of or of or from the literature relevant clinical studies were identified and of the The and a from were a of that topics related to the evidence review of the studies not provide and were A of evidence. A complete used to these Guidelines, by is available as 2, each reported in a study was as an evidence a or The were summarized to a assessment for each evidence formal to evidence studies with and information for These were (1) catheters, (2) catheter (3) and catheter (4) a catheter a a site, and (5) guidance for or were obtained for and were obtained for were as (1) the based on of the reported from the studies, and (2) the of the studies by each of the by the of the An based on the for study using was used with An level was set at < for of the studies were to among the study were obtained when significant was found (P < for a was for studies was and for research were be as significant agree with both of are In the of findings from both the and agree with each other to be as among Task Force members and two methodologists was by using a for were as (1) of study (2) of (3) evidence and (4) literature for were (1) study (2) of (3) (4) literature These to of was obtained from including (1) survey opinion from consultants who were selected based on their or in central venous (2) survey opinions solicited from active members of the ASA and (3) from of open forums at two national (4) commentary, and (5) opinion and The survey rate of was of for the consultants surveys were from active ASA members and surveys were from active SPA members survey was to the expert consultants to indicate of the evidence their clinical the Guidelines were The rate of was of The of consultants associated with each were as (1) availability of a standardized equipment set (2) use of a trained assistant (3) use of a checklist or protocol for placement and maintenance (4) use of that include a checklist or protocol (5) intravenous antibiotic prophylaxis (6) aseptic preparation (e.g. , (8) skin preparation selection of catheters with antibiotic or selection of catheter insertion site for of infection catheter fixation methods insertion site catheter maintenance aseptic techniques using an existing central for injection or selection of catheter insertion site for of trauma or injury patient for or venous access insertion and catheter placement guidance of and catheter placement of and placement management of trauma or injury of the that the Guidelines effect on the of on a and that there be an of the of on a case with the implementation of these Guidelines. that or not be to the Guidelines, and that implementation of the Guidelines not in practice that for these Guidelines was from including randomized controlled trials, observational literature, surveys of expert and selected of ASA and SPA information is summarized in with a of each