Practice Guidelines For Central Venous Access PDF

Practice Guidelines for Central Venous Access
A Report by the American Society of Anesthesiologists Task

Force on Central Venous Access
P RACTICE Guidelines are systematically developed rec-

ommendations that assist the practitioner and patient
in 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 132
tions 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 provide
place 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 findings
ments, and their use cannot guarantee any specific outcome. from surveys of expert consultants and randomly selected
Practice Guidelines are subject to revision as warranted by ASA members
the 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 site
tice. 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 of
expert and practitioner opinion, open forum commentary, venous location of the catheter
and 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 injury
A. Definition of Central Venous Access
For these Guidelines, central venous access is defined as
placement 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 in
superior vena cava, inferior vena cava, brachiocephalic veins, a systemic artery.
Developed by the American Society of Anesthesiologists Task B. Purposes of the Guidelines

Force 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 central
M.D., Philadelphia, Pennsylvania; Stuart Grant, M.D., Durham, North
Carolina; Jonathan B. Mark, M.D., Durham, North Carolina; Jeffrey P.
venous catheterization, and (3) improve management of
Morray, 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, Park
Ridge, Illinois. Submitted for publication October 20, 2011. Accepted
for publication October 20, 2011. Supported by the American Society of
C. Focus
Anesthesiologists 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/supervision
October 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, arranged
alphabetically 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 in
the venous subset for central lines defined by the National Health- both the HTML and PDF versions of this article. Links to the
care Safety Network (NHSN). digital files are provided in the HTML text of this article on the
Copyright 2012, the American Society of Anesthesiologists, Inc. Lippincott Journals Web site (www.anesthesiology.org).
Williams & Wilkins. Anesthesiology 2012; 116:539 73
Anesthesiology, V 116 No 3 539 March 2012

Practice Guidelines
Hickman, Quinton, (6) methods of detection or treat- Scientific Evidence

ment 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 literature
pneumothorax or air embolism), with the exception of ca- (e.g., randomized controlled trials, observational studies, case
rotid arterial injury. reports) relevant to each topic was considered when evaluat-
ing the findings. However, for reporting purposes in this
D. 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 following
and individuals who are under the supervision of an anes- paragraphs) is included in the summary.
thesiologist. They also may serve as a resource for other
physicians (e.g., surgeons, radiologists), nurses, or health Category A: Supportive Literature
care providers who manage patients with central venous Randomized controlled trials report statistically significant
catheters. (P 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 supported
anesthesiologists 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 venous
access were reviewed and evaluated. Third, expert consul- Category B: Suggestive Literature
tants were asked to (1) participate in opinion surveys on the Information from observational studies permits inference of
effectiveness 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 comparisons
tions 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 to
finalize the Guidelines. A summary of recommendations Category C: Equivocal Literature
may be found in appendix 1. The literature cannot determine whether there are beneficial
or harmful relationships among clinical interventions and
F. Availability and Strength of Evidence clinical outcomes.
Preparation of these Guidelines followed a rigorous meth- Level 1: Meta-analysis did not find significant differences
odologic process. Evidence was obtained from two principal (P 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 among
Annual Meeting, April 25, 2010, New Orleans, Louisiana, and Inter- groups or conditions or (2) randomized controlled
national 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 methodology
group. Meta-analyses from other sources are reviewed but not or do not permit inference of beneficial or harmful
included as evidence in this document. relationships.
Anesthesiology 2012; 116:539 73 540 Practice Guidelines

SPECIAL ARTICLES
Category D: Insufficient Evidence from Literature Disagree. Median score of 2 (at least 50% of responses are 2
The 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 Preparation
Opinion-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 for
als) 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 to
address each clinical intervention identified in the docu- The literature is insufficient to specifically evaluate the
ment. 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 use
pediatric 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 care
Category A: Expert Opinion unit multidisciplinary checklist is associated with reduced
Survey 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).27 These
Category B: Membership Opinion studies do not permit the assessment of the effect of any
Survey 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 other
ASA 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 and
summarized based on median values. The consultants and ASA members strongly agree that cen-
tral venous catheterization should be performed in a location
Strongly 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 set
Agree. 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 used
Equivocal. 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 standardized
equipment 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 central
formed by an assistant. venous catheter.**

Practice Guidelines
II. Prevention of Infectious Complications 100%), caps (100% and 94.7%), and masks covering both
Interventions intended to prevent infectious complica- the mouth and nose (100% and 98.1%).
tions associated with central venous access include, but are
not limited to (1) intravenous antibiotic prophylaxis, (2)
aseptic techniques (i.e., practitioner aseptic preparation Selection of Antiseptic Solution
and 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 0.013) and catheter-related bacteremia (P
injection 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 and
otics 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 for
egory 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 is
case-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 0.04) and clinical signs of infection
be administered routinely. (P 0.09) (Category C2 evidence).14
Recommendations for Intravenous Antibiotic Prophylaxis. The consultants and ASA members strongly agree that
For 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 whether
case basis. Intravenous antibiotic prophylaxis should not be chlorhexidine-containing solutions should be used for
administered 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 in
Aseptic Preparation and Selection of Antiseptic Solution
children (216 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 Selection
with a control group (i.e., gloves and small drape) reported of Antiseptic Solution
equivocal findings for reduced colonization (P 0.03) and In preparation for the placement of central venous catheters,
catheter-related septicemia (P 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, masks
of specific aseptic activities (e.g., hand washing) or barrier covering both mouth and nose, and full-body patient
precautions (e.g., sterile full-body drapes, sterile gown, drapes). A chlorhexidine-containing solution should be used
gloves, 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 for
gloves, caps, and masks as elements of care bundles that skin preparation should be based on clinical judgment and
result in reduced catheter-related bloodstream infections institutional protocol. If there is a contraindication to chlo-
(Category B2 evidence).27 However, the degree to which each rhexidine, povidone-iodine or alcohol may be used. Unless
particular element contributed to improved outcomes could contraindicated, skin preparation solutions should contain
not be determined. alcohol.
Most consultants and ASA members indicated that the Catheters Containing Antimicrobial Agents. Meta-analysis
following aseptic techniques should be used in preparation of randomized controlled trials1519 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 A1
73.8%); sterile gowns (100% and 87.8%), gloves (100% and evidence). Meta-analysis of randomized controlled trials20 24

SPECIAL ARTICLES
comparing 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 not
trolled trials were equivocal regarding catheter colonization contaminated or potentially contaminated (e.g., burned or
(P 0.16 0.82) (Category C2 evidence).20 22,24 Meta-anal- infected skin, inguinal area, adjacent to tracheostomy or
yses of randomized controlled trials2536 demonstrate that open surgical wound). In adults, selection of an upper
catheters coated with chlorhexidine and silver sulfadiazine body insertion site should be considered to minimize the
reduce 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 evaluate
fection (i.e., catheter colonization and corresponding posi- whether catheter fixation with sutures, staples or tape is as-
tive blood culture) (Category C1 evidence).2527,29 35,37,38 sociated with a higher risk for catheter-related infections
Cases 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 to
microbial Agents. Catheters coated with antibiotics or a evaluate the efficacy of transparent bio-occlusive dressings
combination 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 0.04 0.96)
and anticipated duration of catheter use. The Task Force regarding catheter tip colonization50,51 and inconsistent
notes that catheters containing antimicrobial agents are not a (P 0.004 0.96) regarding catheter-related blood-
substitute for additional infection precautions. stream infection50,52 when chlorhexidine sponge dressings
Selection 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 standard
reported for catheter-related sepsis (P 0.07) (Category C2 dressings (P 0.05) (Category C2 evidence).53 A randomized
evidence).42 A randomized controlled trial comparing the in- controlled trial reports a greater frequency of severe localized
ternal jugular insertion site with the femoral site reports no contact dermatitis when neonates receive chlorhexidine-im-
difference in catheter colonization (P 0.79) or catheter pregnated dressings compared with povidone-iodine im-
related bloodstream infections (P 0.42) (Category C2 evi- pregnated dressings (Category A3 evidence).54
dence).43 Prospective nonrandomized comparative studies The ASA members agree and the consultants strongly
are equivocal (i.e., inconsistent) regarding catheter-related agree that transparent bio-occlusive dressings should be used
colonization44 46 and catheter related bloodstream infec- to protect the site of central venous catheter insertion from
tion46 48 when the internal jugular site is compared with the infection. The consultants and ASA members agree that
subclavian site (Category C3 evidence). A nonrandomized dressings containing chlorhexidine may be used to reduce the
comparative study of burn patients reports that catheter col- risk of catheter-related infection. SPA members are equivocal
onization and bacteremia occur more frequently the closer regarding whether dressings containing chlorhexidine may
the catheter insertion site is to the burn wound (Category B1 be used for skin preparation in neonates (younger than 44
evidence).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 2
site is preferred to minimize catheter-related risk of infec- yr) and children (216 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 the
risk 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. For
and 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.

Practice Guidelines
Catheter Maintenance. Catheter maintenance consists of (1) connectors with standard caps indicate decreased levels of
determining the optimal duration of catheterization, (2) con- microbial contamination of stopcock entry ports with
ducting 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 reported
stead of selecting a new insertion site. (P 0.3 0.9) (Category C2 evidence).65,66
Nonrandomized comparative studies indicate that longer The consultants and ASA members strongly agree that
catheterizations are associated with higher rates of catheter catheter access ports should be wiped with an appropriate
colonization, 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-case
specified time intervals between catheter site inspections are basis. The consultants and ASA members strongly agree that
associated 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 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 wiped
versus 7-day intervals (Category C2 evidence).56,57 Meta-anal- with an appropriate antiseptic before each access when using
ysis 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 be
used to change catheters compared with the use of new in- capped when not in use. Needleless catheter access ports may
sertion sites (Category C1 evidence). be used on a case-by-case basis.
The ASA members agree and the consultants strongly
agree that the duration of catheterization should be based on III. Prevention of Mechanical Trauma or Injury
clinical need. The consultants and ASA members strongly Interventions intended to prevent mechanical trauma or
agree that (1) the clinical need for keeping the catheter in injury associated with central venous access include, but
place 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 insertion
Recommendations for Catheter Maintenance. The dura- sites reports that the femoral site had a higher frequency of
tion 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 reports
longer deemed clinically necessary. The catheter insertion equivocal findings for arterial puncture (P 0.35), deep
site should be inspected daily for signs of infection, and the venous thrombosis (P 0.62) or hematoma formation (P
catheter should be changed or removed when catheter inser- 0.47) (Category C2 evidence).43 A randomized controlled trial
tion 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 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 site
Catheter for Injection or Aspiration is compared with the subclavian insertion site (Category
C3 evidence).68 70
Aseptic techniques using an existing central venous catheter
for injection or aspiration consist of (1) wiping the port with Most consultants and ASA members indicate that the
an appropriate antiseptic, (2) capping stopcocks or access internal jugular insertion site is preferred to minimize
ports, 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 minimize
ports 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 on
dence). Randomized controlled trials comparing needleless clinical need and practitioner judgment, experience, and

SPECIAL ARTICLES
skill. In adults, selection of an upper body insertion site tion, and the skill and experience of the operator. The
should be considered to minimize the risk of thrombotic consultants and ASA members agree that the selection of a
complications. modified Seldinger technique versus a Seldinger technique
2. Positioning the Patient for Needle Insertion and Cath- should be based on the clinical situation and the skill and
eter Placement. Nonrandomized studies comparing the Tren- experience of the operator. The consultants and ASA
delenburg (i.e., head down) position with the normal supine members agree that the number of insertion attempts
position indicates that the right internal jugular vein increases in should be based on clinical judgment. The ASA members
diameter and cross-sectional area to a greater extent when adult agree and the consultants strongly agree that the decision
patients are placed in the Trendelenburg position (Category B2 to place two central catheters in a single vein should be
evidence).7176 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 of
when 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 needle
in 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 the
Recommendations for Positioning the Patient for Needle operator. The decision to use a thin-wall needle technique
Insertion and Catheter Placement or a catheter-over-the-needle technique should be based at
When clinically appropriate and feasible, central venous ac- least in part on the method used to confirm that the wire
cess in the neck or chest should be performed with the patient resides in the vein before a dilator or large-bore catheter is
in 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 on
ment includes (1) selection of catheter size and type, (2) use of a clinical judgment. The decision to place two catheters in a
wire-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 Catheter
the-catheter technique (i.e., modified Seldinger technique), (3) Placement. Guidance for needle, wire, and catheter placement
limiting the number of insertion attempts, and (4) introducing includes ultrasound imaging for the purpose of prepuncture
two 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 venous
matoma, pseudoaneurysm, arteriovenous fistula, arterial dis- location (i.e., real time or dynamic ultrasound). Verification of
section, neurologic injury including stroke, and severe or needle, wire, or catheter location includes any one or more of the
lethal airway obstruction) when there is unintentional ar- following methods: (1) ultrasound, (2) manometry, (3) pressure
terial 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 literature
is insufficient to evaluate whether the risk of injury or Guidance
trauma 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 insertion
central 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 0.025 0.57) (Category C2 evidence).90 92 In
carotid artery puncture (P 0.65) or hematoma (P addition, the literature is equivocal regarding subclavian vein
0.48) were noted (Category C3 evidence).89 access (P 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 localization

Practice Guidelines
Fig. 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 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. ECG electrocardiography; TEE 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 higher
garding 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 decreased

SPECIAL ARTICLES
rates 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 proper
venipuncture 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 that
fewer insertion attempts with real-time ultrasound guided veni- before insertion of a dilator or large- bore catheter over a
puncture (Category A2 evidence),105,106 and one randomized wire, venous access should be confirmed for the catheter or
clinical 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 not
with the anatomic landmark approach (Category A3 evi- be relied upon to confirm venous access. The consultants
dence).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 in
ports a higher first-attempt success rate and fewer needle the vein after traveling through a catheter or thin-wall needle
passes 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 chest
guidance during venous access when either the internal radiograph should be performed to confirm the location of
jugular 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 catheters
use 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 postoperative
Verification 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 venous
in the Vein. A retrospective observational study reports that positioning of the catheter before use.
manometry can detect arterial punctures not identified by blood
flow and color (Category B2 evidence).108 The literature is insuf- Recommendations for Guidance and Verification of
ficient to address ultrasound, pressure-waveform analysis, blood Needle, Wire, and Catheter Placement
gas 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 placement
venous access (Category D evidence). in elective situations:
Confirming Venous Residence of the Wire. An observational
Use static ultrasound imaging before prepping and
study indicates that ultrasound can be used to confirm venous draping for prepuncture identification of anatomy to
placement 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. Static
ageal 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 localization
firming venous residence of the wire (Category D evidence), al-
and venipuncture when the internal jugular vein is selected
though narrow complex electrocardiographic ectopy is recog-
for cannulation (see fig. 1). Real-time ultrasound may be
nized by the Task Force as an indicator of venous location of the
used when the subclavian or femoral vein is selected. The
wire. 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 of
egory 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 a
tem. Studies with observational findings indicate that fluo- thin-wall needle, confirm venous access. Methods for
confirming that the catheter or thin-wall needle resides in
roscopy113,115 and chest radiography115125 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 gas
placement may take place after the wire is threaded. measurement. Blood color or absence of pulsatile flow

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 venous
Case reports of adult patients with arterial puncture by a catheter.
large bore catheter/vessel dilator during attempted central
venous catheterization indicate severe complications (e.g., Prevention of Infectious Complications
cerebral 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
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, use
tended 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 covering
surgeon 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 skin
ter 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- For neonates, the use of a chlorhexidine-containing solution
ventional radiologist should be immediately consulted before for skin preparation should be based on clinical judgment and
deciding on whether to remove the catheter, either surgically or institutional protocol.

SPECIAL ARTICLES
If there is a contraindication to chlorhexidine, povidone-io- 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
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- Selection of the smallest size catheter appropriate for the
tion of catheter use. clinical situation should be considered.
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.
An insertion site should be selected that is not contami-
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
In adults, selection of an upper body insertion site should threaded.
be considered to minimize the risk of infection. 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.
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.
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. Static ultrasound may be used when the subclavian or femoral
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
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 Real-time ultrasound may be used when the subclavian or
infection. femoral vein is selected.
Real-time ultrasound may not be feasible in emergency
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.
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 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-

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
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
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
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 96 2
Applicator, chloraprep 10.5 ml 3
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 6.08.0 (2 each size) 10
Management of Arterial Trauma or Injury Arising from Packs, sterile gowns 2
Central 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
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.

SPECIAL ARTICLES
Appendix 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. Patients Allergy Assessed (especially to Lidocaine or Heparin)
3. Patients 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
Patients 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)

Practice Guidelines
Appendix 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:

SPECIAL ARTICLES
Appendix 4. Example Duties Performed by an Silver-impregnated catheters versus no coating

Assistant for Central Venous Catheterization Chlorhexidine combined with silver sulfadiazine catheter
coating versus no coating
Reads 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
Subclavian
Verbally 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 fixation
Brings the ultrasound machine, positions it, turns it on, Suture, staple, or tape
makes adjustments as needed. Insertion site dressings
Provides moderate sedation (if registered nurse) if Clear plastic, chlorhexidine, gauze and tape, cyanoacrylate,
needed. antimicrobial dressings, patch, antibiotic ointment
Participates in time-out before procedure. Catheter maintenance
Washes 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 catheters
Attends to patient requests if patient awake during
procedure. Specified time intervals
Assists with patient positioning. Specified time interval versus no specified time interval (i.e., as
Assists 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 site
Assists with sterile ultrasound sleeve application to Aseptic techniques using an existing central line for injection or
ultrasound probe. aspiration
Assists with attachment of intravenous lines or Wiping ports with alcohol
pressure lines if needed. Capping stopcocks
Assists 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
Subclavian
Appendix 5: Methods and Analyses
Femoral
State of the Literature Trendelenburg versus supine position
For these Guidelines, a literature review was used in combination Needle insertion and catheter placement
with 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 catheter
evidence linkages, or statements regarding potential relationships Placement of two catheters in the same vein
between clinical interventions and outcomes. The interventions Use of a Seldinger technique versus a modified Seldinger
listed below were examined to assess their effect on a variety of technique
outcomes 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 puncture.

Practice Guidelines
For the literature review, potentially relevant clinical studies were 0.70, Var (Sav) 0.016; (3) linkage assignment, Sav 0.94, Var
identified via electronic and manual searches of the literature. The (Sav) 0.002; (4) literature database inclusion, Sav 0.65, Var
electronic and manual searches covered a 44-yr period from 1968 (Sav) 0.034. These values represent moderate to high levels of
through 2011. More than 2,000 citations were initially identified, agreement.
yielding a total of 671 nonoverlapping articles that addressed topics
related to the evidence linkages. After review of the articles, 383 Consensus-based Evidence
studies did not provide direct evidence, and were subsequently Consensus was obtained from multiple sources, including (1) sur-
eliminated. A total of 288 articles contained direct linkage-related vey opinion from consultants who were selected based on their
evidence. A complete bibliography used to develop these Guide- knowledge or expertise in central venous access, (2) survey opinions
lines, organized by section, is available as Supplemental Digital solicited from active members of the ASA and SPA, (3) testimony
Content 2, http://links.lww.com/ALN/A784. from attendees of publicly-held open forums at two national anes-
Initially, each pertinent outcome reported in a study was classi- thesia meetings, (4) Internet commentary, and (5) task force opin-
fied as supporting an evidence linkage, refuting a linkage, or equiv- ion and interpretation. The survey rate of return was 41.0% (n 55
ocal. The results were then summarized to obtain a directional of 134) for the consultants (table 2), 530 surveys were received from
assessment for each evidence linkage before conducting formal active ASA members (table 3), and 251 surveys were received from
meta-analyses. Literature pertaining to five evidence linkages con- active SPA members (table 4).
tained enough studies with well-defined experimental designs and An additional survey was sent to the expert consultants asking
statistical information sufficient for meta-analyses (table 1). These them to indicate which, if any, of the evidence linkages would
linkages were (1) antimicrobial catheters, (2) silver sulfadiazine change their clinical practices if the Guidelines were instituted. The
catheter coatings, (3) chlorhexidine and silver sulfadiazine catheter rate of return was 16% (n 22 of 134). The percentage of respond-
coatings, (4) changing a catheter over a wire versus a new site, and ing consultants expecting no change associated with each linkage
(5) ultrasound guidance for venipuncture. were as follows: (1) availability of a standardized equipment set
General variance-based effect-size estimates or combined prob- 91.8%, (2) use of a trained assistant 83.7%, (3) use of a checklist or
ability tests were obtained for continuous outcome measures, and protocol for placement and maintenance 75.5%, (4) use of bundles
Mantel-Haenszel odds-ratios were obtained for dichotomous out- that include a checklist or protocol 87.8%, (5) intravenous antibiotic
come measures. Two combined probability tests were employed as prophylaxis 93.9%, (6) aseptic preparation (e.g., hand washing, caps,
follows: (1) the Fisher combined test, producing chi-square values masks) 98.0%, (8) skin preparation 98.0%, (9) selection of cath-
based on logarithmic transformations of the reported P values from eters with antibiotic or antiseptic coatings/impregnation 89.8%,
the independent studies, and (2) the Stouffer combined test, pro- (10) selection of catheter insertion site for prevention of infection
viding weighted representation of the studies by weighting each of 100%, (11) catheter fixation methods 89.8%, (12) insertion site
the standard normal deviates by the size of the sample. An odds- dressings 100%, (13) catheter maintenance 100%, (14) aseptic
ratio procedure based on the Mantel-Haenszel method for combin- techniques using an existing central line for injection or aspiration
ing study results using 2 2 tables was used with outcome fre- 95.9%, (15) selection of catheter insertion site for prevention of me-
quency information. An acceptable significance level was set at P chanical trauma or injury 100%, (16) Trendelenburg versus supine
0.01 (one-tailed). Tests for heterogeneity of the independent stud- patient positioning for neck or chest venous access 100%, (17)
ies were conducted to assure consistency among the study results. needle insertion and catheter placement 100%, (18) guidance
DerSimonian-Laird random-effects odds ratios were obtained of needle, wire, and catheter placement 89.8%, (19) verification of
when significant heterogeneity was found (P 0.01). To control needle puncture and placement 98.0%, (20) management of trauma
for potential publishing bias, a fail-safe n value was calculated. or injury 100%.
No search for unpublished studies was conducted, and no reliability Fifty-seven percent of the respondents indicated that the Guide-
tests for locating research results were done. To be accepted as lines would have no effect on the amount of time spent on a typical
significant findings, Mantel-Haenszel odds ratios must agree with case, and 43% indicated that there would be an increase of the
combined test results whenever both types of data are assessed. In amount of time spent on a typical case with the implementation of
the absence of Mantel-Haenszel odds-ratios, findings from both the these Guidelines. Seventy-four percent indicated that new equip-
Fisher and weighted Stouffer combined tests must agree with each ment, supplies, or training would not be needed to implement the
other to be acceptable as significant. Guidelines, and 78% indicated that implementation of the Guide-
Interobserver agreement among Task Force members and two lines would not require changes in practice that would affect costs.
methodologists was established by interrater reliability testing.
Agreement levels using a kappa () statistic for two-rater agreement Combined Sources of Evidence
pairs were as follows: (1) type of study design, 0.70 1.00l; (2) Evidence for these Guidelines was formally collected from multiple
type of analysis, 0.60 0.84; (3) evidence linkage assignment, sources, including randomized controlled trials, observational liter-
0.911.00; and (4) literature inclusion for database, 0.65 ature, surveys of expert consultants, and randomly selected samples
1.00. Three-rater chance-corrected agreement values were (1) study of ASA and SPA members. This information is summarized in table
design, Sav 0.80, Var (Sav) 0.006; (2) type of analysis, Sav 5, with a brief description of each corresponding recommendation.

SPECIAL ARTICLES
Table 1. Meta-analysis Summary
Heterogeneity
Weighted
Fisher P Stouffer P Effect Odds Confidence P Effect
Evidence Linkages N Chi-square Value Zc Value Size Ratio Interval Values Size
Antibiotic-coated catheters
vs. no coating
Catheter colonization 5 0.35 0.230.55 ns
Silver sulfadiazine catheter
coating vs. no coating
Catheter-related 5 0.70 0.451.10 ns
bloodstream infection
Chlorhexidine silver
sulfadiazine catheter
coating vs. no coating
Catheter-related 12 0.70 0.471.03 ns
bloodstream infection
Changing a catheter over
a wire vs. a new site
Real-time ultrasound
guidance vs. no
ultrasound*
Successful insertion/ 11 7.15 1.3318.27 0.005
cannulation
First attempt success 5 3.24 1.935.45 ns
Time to insertion 6 70.67 0.001 7.15 0.001 0.23 ns ns
Arterial puncture 10 0.24 0.150.38 ns
* Findings represent studies addressing internal jugular access. Random-effects odds ratio.
ns P 0.01.
Table 2. Consultant Survey Responses*
Percent Responding to Each Item

Strongly Strongly
N Agree Agree Equivocal Disagree Disagree
I. Resource preparation
1. Central venous catheterization should be 54 92.6* 7.4 0.0 0.0 0.0
performed in a location that permits the use of
aseptic techniques
2. A standardized equipment set should be 55 78.2* 16.4 5.4 0.0 0.0
available for central venous access
3. A trained assistant should be present during 54 33.3 29.6* 16.7 18.4 1.9
placement of a central venous catheter
4. A checklist or protocol should be used for the 54 59.3* 20.4 9.3 9.3 1.8
placement and maintenance of central venous
catheters
II. Prevention of infectious complications
5. Intravenous antibiotic prophylaxis should not be 55 43.6 32.7* 12.7 7.3 3.6
administered routinely
6. For immunocompromised patients and high-risk 55 23.6 36.4* 27.3 10.9 1.8
neonates, intravenous antibiotic prophylaxis may
be administered on a case-by-case basis
7. The practitioner should use the following aseptic
techniques in preparation for the placement of
central venous catheters (check all that apply) 55 Percentage
Hand washing 100.0
Sterile full-body drapes 87.3
Sterile gowns 100.0
Gloves 100.0
Caps 100.0
Masks covering both mouth and nose 100.0
(continued)

Practice Guidelines
Table 2. Continued

Strongly Strongly
8. Chlorhexidine with alcohol should be used for 55 72.7* 27.3 0.0 0.0 0.0
skin preparation
9. Catheters coated with antibiotics or a 55 38.2 45.5* 16.3 0.0 0.0
combination of chlorhexidine and silver
sulfadiazine may be used in selected patients
based on infectious risk, cost, and anticipated
duration of catheter use
10. Please indicate your preferred central venous
catheter insertion site to minimize catheter-
related risk of infection (check one) 55 Percentage
Internal jugular 41.8
Subclavian 52.7
Femoral 0.0
No preference 5.5
11. Femoral catheterization should be avoided when 54 37.0 53.7* 3.7 3.7 1.9
possible to minimize the risk of infection
12. An insertion site should be selected that is not 53 71.7* 24.5 7.8 0.0 0.0
contaminated or potentially contaminated (e.g.,
burned or infected skin, inguinal area, adjacent
to tracheostomy or open surgical wound)
13. Please indicate your preferred catheter fixation
technique to minimize catheter-related risk of
infection (check one) 54 Percentage
Sutures 70.4
Staples 3.7
Tape 5.5
No preference 20.4
14. Transparent bio-occlusive dressings should be 55 52.7* 41.8 3.6 1.8 0.0
used to protect the site of central venous
catheter insertion from infection
15. Dressings containing chlorhexidine may be used 55 20.0 34.6* 45.4 0.0 0.0
to reduce the risk of catheter-related infection
16. The duration of catheterization should be based 55 61.8* 30.9 0.0 7.3 0.0
on clinical need
17. The clinical need for keeping a catheter in place 53 90.6* 9.4 0.0 0.0 0.0
should be assessed daily
18. Catheters should be promptly removed when 54 88.9* 11.1 0.0 0.0 0.0
deemed no longer clinically necessary
19. The catheter site should be inspected daily for 54 88.9* 11.1 0.0 0.0 0.0
signs of infection
20. The catheter should be changed or removed 55 74.6* 20.0 3.6 1.8 0.0
when infection is suspected
21. When catheter-related infection is suspected, 55 70.9* 27.3 1.8 0.0 0.0
replacing the catheter using a new insertion site
is preferable to changing the catheter over a
guidewire
22. Catheter access ports should be wiped with an 55 69.1* 21.8 7.3 1.8 0.0
appropriate antiseptic before each access
23. Needleless catheter access ports may be used 55 30.9 47.3* 12.7 3.6 5.5
on a case-by-case basis
24. Central venous catheter stopcocks should be 54 81.5* 18.5 0.0 0.0 0.0
capped when not in use
(continued)

SPECIAL ARTICLES
Table 2. Continued

Strongly Strongly
III. Prevention of mechanical trauma or injury

catheter insertion site to minimize catheter
cannulation-related risk of injury or trauma
(check one) 55 Percentage
Subclavian 9.1
Femoral 3.6
No preference 5.6
related risk of thromboembolic injury or trauma
(check one) 55 Percentage
Subclavian 7.3
Femoral 0.0
No preference 16.3
27. When clinically appropriate and feasible, central 54 51.9* 33.3 9.6 5.6 0.0
venous access in the neck or chest should be
performed in the Trendelenburg position
28. Selection of catheter type (i.e., gauge, length, 55 49.1 38.2* 9.1 3.6 0.0
number of lumens) and composition (e.g.,
polyurethane, Teflon) should be based on the
clinical situation and skill/experience of the
operator
29. Selection of a modified Seldinger technique vs. 55 36.4 49.1* 5.4 7.3 1.8
a Seldinger technique should be based on the
clinical situation and the skill/experience of the
operator
30. The number of insertion attempts should be 55 45.5 32.7* 3.6 16.4 1.8
based on clinical judgment
31. The decision to place two catheters in a single 55 55.6* 40.0 3.6 1.8 0.0
vein should be made on a case-by-case basis
32. Ultrasound imaging (i.e., static) should be used 53 49.1 26.4* 11.3 9.4 3.8
in elective situations for pre-puncture
identification of anatomy and vessel localization
when the internal jugular vein is selected for
cannulation
33. Ultrasound imaging (i.e., static) should be used in 55 12.7 18.2 32.7* 25.5 10.9
elective situations for pre-puncture identification of
anatomy and vessel localization when the subclavian
vein is selected for cannulation
34. Ultrasound imaging (i.e., static) should be used 55 18.2 32.7* 21.8 23.6 3.6
in elective situations for pre-puncture
identification of anatomy and vessel localization
when the femoral vein is selected for
cannulation
35. When available, real-time ultrasound should be 54 44.4 33.3* 13.0 9.3 0.0
used for guidance during venous access when
the internal jugular vein is selected for
cannulation
36. When available, real-time ultrasound should be 53 11.3 17.0 37.7* 28.3 5.7
the subclavian vein is selected for cannulation
(continued)

Practice Guidelines
Table 2. Continued

Strongly Strongly
37. When available, real-time ultrasound should be 54 14.8 35.2* 33.3 14.8 1.9
the femoral vein is selected for cannulation
38. Before insertion of a dilator or large bore 54 57.4* 25.9 7.4 9.3 0.0
catheter over a wire, venous access should be
confirmed for the catheter or thin-wall needle
that accesses the vein
39. Before insertion of a dilator or large bore 55 29.1 29.1* 25.5 12.7 3.6
catheter over a wire, venous access should be
confirmed for the wire that subsequently resides
in the vein after traveling through a catheter or
thin-wall needle
40. When feasible, both the location of the catheter 55 25.4 38.2* 18.2 15.6 3.6
or thin-wall needle and wire should be
confirmed
41. A chest radiograph should be performed to 55 30.9 41.8* 9.1 14.5 3.6
confirm the location of the catheter tip as soon
after catheterization as clinically appropriate
42. For central venous catheters placed in the 55 47.3 50.9* 0.0 1.8 0.0
operating room, a confirmatory chest radiograph
may be performed in the early postoperative
period
43. If a chest radiograph will be deferred to the 55 56.4* 30.9 5.4 7.3 0.0
postoperative period, pressure/waveform
analysis, blood gas analysis, ultrasound or
fluoroscopy should be used to confirm venous
positioning of the catheter before use
IV. Management of arterial trauma or injury arising
from central venous
44. When unintended cannulation of an arterial 55 45.4 36.4* 7.3 9.1 1.8
vessel with a large bore catheter occurs, the
catheter should be left in place and a general or
vascular surgeon should be consulted
* N number of consultants who responded to each item. An asterisk next to a percentage score indicates the median.

SPECIAL ARTICLES
Table 3. ASA Member Survey Responses*

Strongly Strongly
1. Central venous catheterization should be 529 78.1* 19.1 2.1 0.8 0.0
performed in a location that permits the
use of aseptic techniques
2. A standardized equipment set should be 530 64.5* 30.0 4.2 0.9 0.4
available for central venous access
3. A trained assistant should be present during 526 24.1 35.6* 24.0 13.1 3.2
placement of a central venous catheter
4. A checklist or protocol should be used for 528 35.6 37.5* 16.3 8.9 1.7
The placement and maintenance of central
venous catheters
II. Prevention of infectious complications
5. Intravenous antibiotic prophylaxis should 526 29.7 44.5* 16.9 7.0 1.9
not be administered routinely
6. For immunocompromised patients and 523 25.0 54.1* 15.9 4.2 0.8
high-risk neonates, intravenous antibiotic
prophylaxis may be administered on a
case-by-case basis
7. The practitioner should use the following
aseptic techniques in preparation for the
placement of central venous catheters
(check all that apply) 524 Percentage
Hand washing 96.0
Sterile full-body drapes 73.8
Sterile gowns 87.8
Gloves 100.0
Caps 94.7
Masks covering both mouth and nose 98.1
8. Chlorhexidine with alcohol should be used 522 57.3* 34.1 7.8 0.8 0.0
for skin preparation
9. Catheters coated with antibiotics or a 526 24.3 54.8* 19.2 1.7 0.0
combination of chlorhexidine and silver
sulfadiazine may be used in selected
patients based on infectious risk, cost,
and anticipated duration of catheter use
Subclavian 44.3
Femoral 0.0
No preference 4.4
11. Femoral catheterization should be avoided 525 33.9 49.7* 9.3 4.7 2.3
when possible to minimize the risk of
infection
12. An insertion site should be selected that is 523 58.9* 37.9 2.5 0.7 0.0
not contaminated or potentially
contaminated (e.g., burned or infected
skin, inguinal area, adjacent to
tracheostomy or open surgical wound)
(continued)

Practice Guidelines
Table 3. Continued

Strongly Strongly
13. Please indicate your preferred catheter

fixation technique to minimize catheter-
Sutures 80.2
Staples 5.7
Tape 3.6
No preference 10.5
14. Transparent bio-occlusive dressings 522 46.9 44.4* 6.5 1.3 0.8
should be used to protect the site of
central venous catheter insertion from
infection
15. Dressings containing chlorhexidine may be 525 18.7 37.9* 41.3 1.9 0.2
used to reduce the risk of catheter-related
infection
16. The duration of catheterization should be 523 49.5 44.5* 3.1 2.5 0.4
based on clinical need
17. The clinical need for keeping a catheter in 523 65.8* 32.5 1.3 0.4 0.0
place should be assessed daily
18. Catheters should be promptly removed 521 78.7* 20.9 0.4 0.0 0.0
when deemed no longer clinically
necessary
19. The catheter site should be inspected 521 79.1* 19.6 1.1 0.2 0.0
daily for signs of infection
20. The catheter should be changed or 524 72.7* 24.4 2.5 0.2 0.2
removed when infection is suspected
21. When catheter-related infection is 525 64.8* 30.7 3.8 0.8 0.0
suspected, replacing the catheter using a
new insertion site is preferable to
changing the catheter over a guidewire
22. Catheter access ports should be wiped 522 64.6* 31.0 3.4 1.0 0.0
with an appropriate antiseptic before each
access
23. Needleless catheter access ports may be 522 33.9 51.3* 12.3 1.7 0.8
used on a case-by-case basis
24. Central venous catheter stopcocks should 527 70.6* 26.2 2.6 0.6 0.0
be capped when not in use
III. Prevention of mechanical trauma or injury
25. Please indicate your preferred central
venous catheter insertion site to minimize
catheter cannulation-related risk of injury
or trauma (check one) 525 Percentage
Subclavian 10.7
Femoral 2.7
No preference 7.2
26. Please indicate your preferred central
venous catheter insertion site to minimize
catheter-related risk of thromboembolic
injury or trauma (check one) 525 Percentage
Subclavian 12.8
Femoral 1.9
No preference 17.7
(continued)

SPECIAL ARTICLES
Table 3. Continued

Strongly Strongly
27. When clinically appropriate and feasible, 528 57.0* 37.7 3.0 1.9 0.4
central venous access in the neck or
chest should be performed in the
Trendelenburg position
28. Selection of catheter type (i.e., gauge, 530 52.1* 38.1 6.2 3.4 0.0
length, number of lumens) and
composition (e.g., polyurethane, Teflon)
should be based on the clinical situation
and skill/experience of the operator
29. Selection of a modified Seldinger 531 47.8 36.9* 9.8 4.7 0.8
technique vs. a Seldinger technique
should be based on the clinical situation
and the skill/experience of the operator
30. The number of insertion attempts should 528 47.3 43.6* 4.2 3.8 1.1
be based on clinical judgment
31. The decision to place two catheters in a 527 45.9 36.2* 12.1 4.4 1.3
single vein should be made on a case-by-
case basis
32. Ultrasound imaging (i.e., static) should be 526 28.9 25.1* 21.3 18.8 5.9
used in elective situations for pre-puncture
identification of anatomy and vessel
localization when the internal jugular vein
is selected for cannulation
33. Ultrasound imaging (i.e., static) should be 528 9.7 14.2 41.5* 26.5 8.1
localization when the subclavian vein is
selected for cannulation
34. Ultrasound imaging (i.e., static) should be 527 11.9 29.8 30.6* 21.4 6.3
localization when the femoral vein is
35. When available, real time ultrasound 525 24.0 24.2 23.2* 21.5 7.1
should be used for guidance during
venous access when the internal jugular
vein is selected for cannulation
36. When available, real time ultrasound 530 8.1 13.4 42.1* 27.9 8.5
venous access when the subclavian vein is
37. When available, real-time ultrasound 528 13.5 23.5 31.4* 25.0 6.6
venous access when the femoral vein is
38. Before insertion of a dilator or large bore 524 52.9* 32.1 8.4 6.3 0.4
catheter over a wire, venous access
should be confirmed for the catheter or
thin-wall needle that accesses the vein
39. Before insertion of a dilator or large bore 524 24.0 25.4 25.6* 22.9 2.1
catheter over a wire, venous access should
be confirmed for the wire that subsequently
resides in the vein after traveling through a
catheter or thin-wall needle
(continued)

Practice Guidelines
Table 3. Continued

Strongly Strongly
40. When feasible, both the location of the 526 23.8 32.5* 22.1 19.4 2.3
catheter or thin-wall needle and wire
should be confirmed
41. A chest radiograph should be performed 525 39.8 45.5* 7.1 7.0 0.6
to confirm the location of the catheter tip
as soon following catheterization as
clinically appropriate
42. For central venous catheters placed in the 524 46.8 48.1* 2.5 1.9 0.8
operating room, a confirmatory chest
radiograph may be performed in the early
postoperative period
43. If a chest radiograph will be deferred to 527 33.0 35.3* 12.7 16.7 2.3
the postoperative period,
pressure/waveform analysis, blood gas
analysis, ultrasound or fluoroscopy should
be used to confirm venous positioning of
the catheter before use
IV. Management of arterial trauma or injury
arising from central venous
44. When unintended cannulation of an 526 28.5 35.6* 16.3 17.9 1.7
arterial vessel with a large bore catheter
occurs, the catheter should be left in
place and a general or vascular surgeon
should be consulted
* Number of ASA members who responded to each item. An asterisk next to a percentage score indicates the median.

SPECIAL ARTICLES
Table 4. SPA Member Survey Responses*

Strongly Strongly
1. A chlorhexidine-containing solution should 250 17.2 26.0 31.6* 17.2 8.0

be used for skin preparation in neonates
2. A chlorhexidine-containing solution should 248 46.0 40.3* 11.3 2.4 0.0
be used for skin preparation in infants
3. A chlorhexidine-containing solution should 249 62.7* 30.9 5.2 1.2 0.0
be used for skin preparation in children
4. Dressings containing chlorhexidine may be 243 7.0 14.0 52.2* 20.2 6.6
used in neonates
used in infants
used in children
7. When unintended cannulation of an arterial
vessel with a large bore catheter occurs in
neonates (check one) 244 Percentage
The catheter should be left in place5 54.9
The catheter may be nonsurgically 45.1
removed
vessel with a large-bore catheter occurs in
infants (check one) 249 Percentage
The catheter should be left in place 43.8
removed
vessel with a large bore catheter occurs in
children (check one) 244 Percentage
The catheter should be left in place 30.0
removed
* Number of SPA members who responded to each item. An asterisk beside a percentage score indicates the median response.
Younger than 44 gestational weeks. Younger than 2 yr. 216 yr of age. The complete wording of the response category is:
The catheter should be left in place and a general surgeon, vascular surgeon, or interventional radiologist should be immediately
consulted before deciding on whether to remove the catheter, either surgically or nonsurgically. # The complete wording of the
response category is: The catheter may be nonsurgically removed without consulting a general surgeon, vascular surgeon, or
interventional radiologist.

Practice Guidelines
Table 5. Evidence Summary*
Evidence Consultant ASA Member SPA Member Guideline

Interventions Category1 Survey2 Survey2 Survey2 Recommendation
Catheterization in environment D Strongly agree Strongly agree Should be performed
that permits use of
aseptic techniques
Standardized equipment set D Strongly agree Strongly agree Should be available
An assistant D Agree (trained) Agree (trained) Should be used
A checklist or protocol B23 Strongly agree Agree Should be used
II. Prevention of infectious
complications
Intravenous antibiotic
prophylaxis
Prophylactic intravenous D Agree Agree Should not be routinely
antibiotics should administered
not be administered
routinely
Prophylactic intravenous A24 Agree Agree Administer on a case-by-
antibiotics should be case basis
administered to
immunocompromised
patients and high-
risk neonates
Aseptic techniques and
barrier precautions:
Maximal barrier vs. gloves C25,6
and small drape
only
Bundled elements: B23
hand-washing,
sterile full body
drapes, sterile,
gloves, caps, and
masks
Specific activities:
Hand washing D 100% agreement 96% agreement Use
Sterile full-body drape D 87% agreement 74% agreement Use
Sterile gown D 100% agreement 88% agreement Use
Sterile gloves D 100% agreement 100% agreement Use
Caps D 100% agreement 95% agreement Use
Masks covering both D 100% agreement 98% agreement Use
mouth and nose
Skin preparation:
Solutions containing
chlorhexidine:
Chlorhexidine with D Strongly agree Strongly agree Should be used for adults,
alcohol (patient age infants and children
not specified)
Antiseptic solutions
containing
chlorhexidine for:
Neonates D Equivocal Should be based on clinical
judgment and
Institutional protocol
Infants D Agree Should be used
Children D Strongly agree Should be used
Solutions containing
alcohol:
Chlorhexidine without C25,7
alcohol vs.
povidone-iodine
without alcohol
Chlorhexidine with D
alcohol vs.
Povidone-iodine
with alcohol
Skin preparation solutions
with vs. without
alcohol:
Chlorhexidine D
(continued)

SPECIAL ARTICLES
Table 5. Continued

Povidone-iodine A35/C28
Skin preparation solutions Use unless contraindicated
containing alcohol
Catheters containing
antimicrobial agents:
Antibiotic-coated A15 Agree (selected Agree (selected Should be used for
catheters pts) pts) selected patients
3 5
Silver-impregnated C1 /C2 No recommendation
catheters
Chlorhexidine and silver A15/B39/C13 Agree (selected Agree (selected Should be used for
sulfadiazine coated pts) pts) selected patients
catheters
Selection of catheter
insertion site:
Internal jugular vs. C23,5/C33,5 Majority prefer Majority prefer Site selection should be
subclavian subclavian site internal jugular based on clinical need to
site minimize risk of catheter-
related infection
Subclavian vs. femoral A35/C24 Agree (avoid Agree (avoid Site selection should be
femoral) femoral) based on clinical need.
In adults, upper body
site should be
considered to minimize
risk of infection
Catheter fixation:
Risk of catheter-related D Majority prefer Majority prefer Should be determined on a
infections with suture suture local or institutional basis
suture, staple, tape
Catheter insertion site
dressings:
Transparent bio-occlusive D Strongly agree Strongly agree Should be used
Chlorhexidine sponge C23,5 Agree Agree May be used unless
dressings (patient contraindicated
age not specified)
Chlorhexidine- A310 Should be based on clinical
impregnated judgment and institutional
transparent protocol
dressings for
neonates
Chlorhexidine sponge
dressings
For neonates Equivocal Should be based on clinical
judgment and
institutional protocol
For infants Agree May be used, unless
contraindicated
For children Agree May be used, unless
contraindicated
5
Silver-impregnated C2 No recommendation
transparent
dressings
Catheter maintenance:
Duration of catheterization B24,5
related to higher
colonization/infection
rates
Duration of catheterization Strongly agree Agree Duration should be based
should be based on on clinical need
clinical need
Specific time intervals D
between insertion
site inspections
Catheter change interval C25
3-days vs. 7-days
Daily assessment of Strongly agree Strongly agree Clinical need for keeping
clinical need for catheter in place should
continuing be assessed daily
catheterization
(continued)

Practice Guidelines
Table 5. Continued

Conduct daily catheter Strongly agree Strongly agree Catheter insertion site
site inspections should be inspected
daily for signs of
infection
Change or remove Strongly agree Strongly agree Catheter should be
catheter when changed or removed
infection is when Catheter insertion
suspected site infection is
suspected
When catheter-related C15 Strongly agree Strongly agree When catheter-related
infection is (Suspected (Suspected infection is suspected,
suspected, replace infection) infection) replacing the catheter
catheter using new using a new insertion site
insertion site vs. is preferred
catheter change
over a guidewire
Promptly remove catheter Strongly agree Strongly agree Promptly remove catheter
when deemed no when deemed no longer
longer clinically clinically necessary
necessary
Aseptic techniques using an
existing central
venous catheter:
Wipe port with an D Strongly agree Strongly agree Catheter access ports
appropriate should be wiped with an
antiseptic before appropriate antiseptic
access before each access
Cap stopcocks or access Strongly agree Strongly agree Central venous catheter
ports when not in stopcocks or access
use ports should be capped
when not in use
Needleless catheter
connectors/access
ports vs. standard
caps
Needleless catheter A211/C23 Agree Agree Needless catheter access
connectors/ports vs. (case-by case (case-by case ports may be used on a
standard caps basis) basis) case-by-case basis
III. Prevention of mechanical
trauma or injury
Selection of catheter
insertion site:
Internal jugular vs. C213,14,15,16/C317
subclavian
Subclavian vs. femoral A312
Preferred catheter Majority prefer Majority prefer Insertion site selection
insertion site internal jugular internal jugular should be based on
clinical need and
practitioner judgment,
experience and skill. In
adults, selection of an
upper body insertion site
should be considered to
minimize the risk of
thromboembolic injury or
trauma
Positioning the patient for
needle insertion and
catheter placement:
Trendelenburg vs. normal B218 Strongly agree Strongly agree When clinically appropriate
supine and feasible, central
venous access in the neck
or chest should be
performed with the patient
in the Trendelenburg
position
(continued)

SPECIAL ARTICLES
Table 5. Continued

Needle insertion, wire and

catheter placement:
Selection of catheter size Strongly agree Strongly agree Should be based on the
and type clinical situation and the
skill and experience of
the practitioner; selection
of the smallest size
catheter appropriate for
the clinical situation
should be considered
Large-bore catheters B319 Select the smallest size
associated with catheter appropriate for
unintentional arterial the clinical situation
cannulation
Modified Seldinger vs. D Agree Agree Should be based on the
Seldinger technique clinical situation and the
skill and experience of
the operator; the
decision to use a
catheter-over-the- needle
(modified Seldinger)
technique or a thin-wall
needle (Seldinger)
technique should be
based at least in part on
the method used to
confirm that the wire
resides in the vein before
a dilator or large-bore
catheter is threaded
Limiting the number of D Agree Agree Should be based on clinical
insertion attempts judgment
Introducing two catheters B220/C313,15 Strongly agree Agree Should be decided on a
in the same central (case-by-case) (case-by-case) case-by-case basis
vein
Guidance of needle
placement in
elective situations:
Static ultrasound for
preprocedural
vessel localization
vs. landmark
approach:
Internal jugular vein A321/C222 Agree Agree Use
access (elective (elective
situations) situations)
Subclavian vein access C222 Equivocal Equivocal May be used
(elective (elective
Femoral vein access D Agree Equivocal May be used
(elective (elective
Real-time ultrasound for
guiding needle vs.
landmark approach:
Internal jugular vein A113,21,22,23/A224 Agree Equivocal Use
access (when available) (when available)
24 13,15,16,23
Subclavian vein access A2 /A3 Equivocal Equivocal May be used
(when available) (when available)
Femoral vein access A321,24 Agree Equivocal May be used
(when available) (when available)
(continued)

Practice Guidelines
Table 5. Continued

Verification of venous
access:
Confirm that catheter or Strongly agree Strongly agree Confirm venous access
thin-wall needle is in after insertion of catheter
a vein that went over the
needle or a thin-wall
needle
Ultrasound D An identified method
Manometry B213 An identified method
Pressure waveform D An identified method
analysis
Venous blood gas D An identified method
Absence of pulsatility, D Should not be relied upon
blood color to confirm venous
access (based on Task
Force opinion)
Confirm venous residence Agree Equivocal When using the thin-wall
of the wire needle technique,
confirm venous
residence of the wire
after the wire is threaded
Ultrasound B225 An identified method
Transesophageal B325 An identified method
ultrasound
Continuous D An identified method (based
electrocardiography on Task Force opinion)
Fluoroscopy D An identified method (based
on Task Force opinion)
Confirm both the location Agree Agree Confirm if there is any
of the catheter or (when feasible) (when feasible) uncertainty that the
thin-wall needle and catheter or wire resides
wire in the vein
Verification of catheter
placement:
Confirmation of final Confirm the final position of
position of tip of the catheter tip as soon as
catheter clinically appropriate (based
on Task Force opinion)
Fluoroscopy B226 Strongly agree Agree An identified method
Chest radiograph B226 Agree Agree An identified method
Continuous A226 An identified method
electrocardiography
Unintended cannulation of
an arterial vessel
with a large bore
catheter:
Leave catheter in place B327 Agree Agree For adults, the catheter
(patient age not should be left in place
specified) and a general surgeon, a
vascular surgeon, or an
interventional radiologist
should be immediately
consulted
For neonates Majority prefer Should be based on clinical
leaving in place judgment
For infants Majority prefer Should be based on clinical
nonsurgical judgment
removal
(continued)

SPECIAL ARTICLES
Table 5. Continued

For children Majority prefer Should be based on clinical

Nonsurgical removal judgment
* Categories of evidence for literature: Category A: Supportive Literature. Randomized controlled trials report statistically significant
(P 0.01) differences between clinical interventions for a specified clinical outcome. Level 1: The literature contains multiple
randomized controlled trials, and aggregated findings are supported by meta-analysis. Level 2: The literature contains multiple
randomized controlled trials, but the number of studies is insufficient to conduct a viable meta-analysis for the purpose of these
Guidelines. Level 3: The literature contains a single randomized controlled trial. Category B: Suggestive Literature. Information from
observational studies permits inference of beneficial or harmful relationships among clinical interventions and clinical outcomes. Level
1: The literature contains observational comparisons (e.g., cohort, case-control research designs) of clinical interventions or conditions
and indicates statistically significant differences between clinical interventions for a specified clinical outcome. Level 2: The literature
contains noncomparative observational studies with associative (e.g., relative risk, correlation) or descriptive statistics. Level 3: The
literature contains case reports. Category C: Equivocal Literature. The literature cannot determine whether there are beneficial or
harmful relationships among clinical interventions and clinical outcomes. Level 1: Meta-analysis did not find significant differences (P
0.01) among groups or conditions. Level 2: The number of studies is insufficient to conduct meta-analysis, and (1) randomized
controlled trials have not found significant differences among groups or conditions or (2) randomized controlled trials report inconsistent
findings. Level 3: Observational studies report inconsistent findings or do not permit inference of beneficial or harmful relationships.
Category D: Insufficient Evidence from Literature. The lack of scientific evidence in the literature is described by the following terms.
Inadequate: The available literature cannot be used to assess relationships among clinical interventions and clinical outcomes. The
literature either does not meet the criteria for content as defined in the Focus of the Guidelines or does not permit a clear interpretation
of findings due to methodological concerns (e.g., confounding in study design or implementation). Silent: No identified studies address
the specified relationships among interventions and outcomes. 1 All meta-analyses are conducted by the ASA methodology group.
Meta-analyses from other sources are reviewed but not included as evidence in this document. 2 Survey data recorded on a 5-point
scale: strongly agree - agree - equivocal - disagree - strongly disagree; reported findings represent the median survey response.
3
Catheter-related bloodstream infection. 4 Catheter-related infection and sepsis. 5 Catheter colonization. 6 Catheter-related septice-
mia. 7 Catheter-related bacteremia. 8 Catheter-related infection and clinical signs of infection. 9 Anaphylactic shock. 10 Localized
contact dermatitis. 11 Microbial contamination of stopcock entry ports. 12 Thrombotic complications. 13 Arterial puncture. 14 Deep vein
thrombosis. 15 Hematoma. 16 Successful venipuncture. 17 Pneumothorax, hemothorax, or arrhythmia. 18 Diameter and cross sectional
area of right internal jugular vein for patients older than 6 yr. 19 Severe injury (e.g., hemorrhage, hematoma, pseudoaneurysm,
arteriovenous fistula, arterial dissection, neurologic injury including stroke, and severe or lethal airway obstruction) may occur.
20
Dysrhythmia. 21 First insertion attempt success rate. 22 Overall successful cannulation rate. 23 Access time. 24 Number of insertion
attempts. 25 Confirmation of venous placement of wire. 26 Identifying the position of the catheter tip. 27 Fewer severe complications in
adult patients.
References ated bloodstream infection rates decline after bundles and

checklists. Pediatrics 2011; 127:436 44
1. Chua C, Wisniewski T, Ramos A, Schlepp M, Fildes JJ,
Kuhls DA: Multidisciplinary trauma intensive care unit check- 7. Warren DK, Cosgrove SE, Diekema DJ, Zuccotti G, Climo
list: Impact on infection rates. J Trauma Nurs 2010; 17: MW, Bolon MK, Tokars JI, Noskin GA, Wong ES, Sepkowitz
163 6 KA, Herwaldt LA, Perl TM, Solomon SL, Fraser VJ, Preven-
sion Epicenter Program: A multicenter intervention to pre-
2. Berenholtz SM, Pronovost PJ, Lipsett PA, Hobson D, Earsing
vent catheter-associated bloodstream infections. Infect
K, Farley JE, Milanovich S, Garrett-Mayer E, Winters BD,
Control Hosp Epidemiol 2006; 27:6629
Rubin HR, Dorman T, Perl TM: Eliminating catheter-related
bloodstream infections in the intensive care unit. Crit Care 8. Boorman D: Todays electronic checklists reduce likelihood
Med 2004; 32:2014 20 of crew errors and help prevent mishaps. ICAO J 2001:
1720-36
3. Higuera F, Rosenthal VD, Duarte P, Ruiz J, Franco G, Safdar N:
The effect of process control on the incidence of central venous 9. Karl R: Briefings, checklists, geese, and surgical safety. Ann
catheter-associated bloodstream infections and mortality in inten- Surg Oncol 2010; 17:8 11
sive care units in Mexico. Crit Care Med 2005; 33:20227 10. Spafford PS, Sinkin RA, Cox C, Reubens L, Powell KR:
4. Miller MR, Griswold M, Harris JM 2nd, Yenokyan G, Huskins Prevention of central venous catheter-related coagulase-
WC, Moss M, Rice TB, Ridling D, Campbell D, Margolis P, negative staphylococcal sepsis in neonates. J Pediatr 1994;
Muething S, Brilli RJ: Decreasing PICU catheter-associated 125:259 63
bloodstream infections: NACHRIs quality transformation 11. Vassilomanolakis M, Plataniotis G, Koumakis G, Hajichras-
efforts. Pediatrics 2010; 125:206 13 tou H, Skouteri H, Dova H, Efremidis AP: Central venous
5. Pronovost P, Needham D, Berenholtz S, Sinopoli D, Chu H, catheter-related infections after bone marrow transplanta-
Cosgrove S, Sexton B, Hyzy R, Welsh R, Roth G, Bander J, tion in patients with malignancies: A prospective study of
Kepros J, Goeschel C: An intervention to decrease catheter- short-course vancomycin prophylaxis. Bone Marrow Trans-
related bloodstream infections in the ICU. N Engl J Med plant 1995; 15:77 80
2006; 355:272532 12. Raad II, Hohn DC, Gilbreath BJ, Suleiman N, Hill LA, Bruso
6. Schulman J, Stricof R, Stevens TP, Horgan M, Gase K, PA, Marts K, Mansfield PF, Bodey GP: Prevention of central
Holzman IR, Koppel RI, Nafday S, Gibbs K, Angert R, Sim- venous catheter-related infections by using maximal sterile
monds A, Furdon SA, Saiman L, New York State Regional barrier precautions during insertion. Infect Control Hosp
Perinatal Care Centers: Statewide NICU central-line-associ- Epidemiol 1994; 15:231 8
13. Maki DG, Ringer M, Alvarado CJ: Prospective randomised
A complete bibliography used to develop these Guidelines, trial of povidone-iodine, alcohol, and chlorhexidine for
arranged alphabetically by author, is available as Supplemental prevention of infection associated with central venous and
Digital Content 1, http://links.lww.com/ALN/A783. arterial catheters. Lancet 1991; 338:339 43

Practice Guidelines
14. Parienti JJ, du Cheyron D, Ramakers M, Malbruny B, Leclercq 29. George SJ, Vuddamalay P, Boscoe MJ: Antiseptic-impreg-
R, Le Coutour X, Charbonneau P, Members of the NACRE nated central venous catheters reduce the incidence of
Study Group: Alcoholic providone-iodine to prevent central bacterial colonization and associated infection in immuno-
venous catheter colonization: A randomized unit crossover compromised transplant patients. Eur J Anaesthesiol 1997;
study. Crit Care Med 2004; 32:708 13 14:428 31
15. Bach A, Darby D, Bo ttiger B, Bo
hrer H, Motsch J, Martin E: 30. Hannan M, Juste RN, Umasanker S, Glendenning A, Night-
Retention of the antibiotic teicoplanin on a hydromer- ingale C, Azadian B, Soni N: Antiseptic-bonded central ve-
coated central venous catheter to prevent bacterial coloni- nous catheters and bacterial colonisation. Anaesthesia
zation in postoperative surgical patients. Intensive Care 1999; 54:868 72
Med 1996; 22:1066 9 31. Heard SO, Wagle M, Vijayakumar E, McLean S, Bruegge-
16. Kamal GD, Pfaller MA, Rempe LE, Jebson PJ: Reduced mann A, Napolitano LM, Edwards LP, OConnell FM, Puyana
intravascular catheter infection by antibiotic bonding: A JC, Doern GV: Influence of triple-lumen central venous
prospective, randomized, controlled trial. JAMA 1991; 265: catheters coated with chlorhexidine and silver sulfadiazine
2364 8 on the incidence of catheter-related bacteremia. Arch In-
17. Len C, Ruiz-Santana S, Rello J, de la Torre MV, Valls J, Alvarez- tern Med 1998; 158:817
Lerma F, Sierra R, Saavedra P, Alvarez-Salgado F: Benefits of 32. Maki DG, Stolz SM, Wheeler S, Mermel LA: Prevention of
minocycline and rifampin-impregnated central venous catheters: central venous catheter-related bloodstream infection by use
A prospective, randomized, double-blind, controlled, multicenter of an antiseptic-impregnated catheter. A randomized, con-
trial. Intensive Care Med 2004; 30:18919 trolled trial. Ann Intern Med 1997; 127:257 66
18. Thornton J, Todd NJ, Webster NR: Central venous line 33. Ostendorf T, Meinhold A, Harter C, Salwender H, Egerer G,
sepsis in the intensive care unit: A study comparing antibi- Geiss HK, Ho AD, Goldschmidt H: Chlorhexidine and silver-
otic coated catheters with plain catheters. Anaesthesia sulfadiazine coated central venous catheters in haematological
1996; 51:1018 20 patientsa double-blind, randomised, prospective, controlled
19. Raad I, Darouiche R, Dupuis J, Abi-Said D, Gabrielli A, trial. Support Care Cancer 2005; 13:9931000
Hachem R, Wall M, Harris R, Jones J, Buzaid A, Robertson C, 34. Rupp ME, Lisco SJ, Lipsett PA, Perl TM, Keating K, Civetta
Shenaq S, Curling P, Burke T, Ericsson C: Central venous JM, Mermel LA, Lee D, Dellinger EP, Donahoe M, Giles D,
catheters coated with minocycline and rifampin for the Pfaller MA, Maki DG, Sherertz R: Effect of a second-gener-
prevention of catheter-related colonization and blood- ation venous catheter impregnated with chlorhexidine and
stream infections: A randomized, double-blind trial. The silver sulfadiazine on central catheter-related infections: A
Texas Medical Center Catheter Study Group. Ann Intern randomized, controlled trial. Ann Intern Med 2005; 143:
Med 1997;127:26774 570 80
20. Bong JJ, Kite P, Wilco MH, McMahon MJ: Prevention of 35. Tennenberg S, Lieser M, McCurdy B, Boomer G, Howington
catheter related bloodstream infection by silver iontopho- E, Newman C, Wolf I: A prospective randomized trial of an
retic central venous catheters: A randomised controlled antibiotic- and antiseptic-coated central venous catheter in
trial. J Clin Pathol 2003; 56:7315 the prevention of catheter-related infections. Arch Surg
21. Boswald M, Lugauer S, Regenfus A, Braun GG, Martus P, 1997; 132:1348 51
Geis C, Scharf J, Bechert T, Greil J, Guggenbichler J-P: 36. van Heerden PV, Webb SAR, Fong S, Golledge CL, Roberts
Reduced rates of catheter-associated infection by use of a BL: Central venous catheters revisited: Infection rates and
new silver-impregnated central venous catheter. Infection an assessment of the new fibrin analysing system brush.
1999;27:56 60 Anaesth Intens Care 1996; 24:330 3
22. Hagau N, Studnicska D, Gavrus RL, Csipak G, Hagau R, Slav- 37. Logghe C, Van Ossel C, DHoore W, Ezzedine H, Wauters G,
covici AV: Central venous catheter colonization and catheter- Haxhe JJ: Evaluation of chlorhexidine and silver-sulfadiazine
related bloodstream infections in critically ill patients: A com- impregnated central venous catheters for the prevention of
parison between standard and silver-integrated catheters. Eur bloodstream infection in leukaemic patients: A randomized
J Anaesthesiol 2009; 26:752 8 controlled trial. J Hosp Infect 1997; 37:14556
23. Harter C, Salwender HJ, Bach A, Egerer G, Goldschmidt H, Ho 38. Pemberton LB, Ross V, Cuddy P, Kremer H, Fessler T,
AD: Catheter-related infection and thrombosis of the internal McGurk E: No difference in catheter sepsis between stan-
jugular vein in hematologic-oncologic patients undergoing dard and antiseptic central venous catheters. A prospective
chemotherapy: A prospective comparison of silver-coated and randomized trial. Arch Surg 1996; 131:986 9
uncoated catheters. Cancer 2002; 94:24551 39. Oda T, Hamasaki J, Kanda N, Mikami K: Anaphylactic shock
24. Kalfon P, de Vaumas C, Samba D, Boulet E, Lefrant JY, induced by an antiseptic-coated central venous catheter.
Eyraud D, Lherm T, Santoli F, Naija W, Riou B: Comparison ANESTHESIOLOGY 1997; 87:1242 4
of silver-impregnated with standard multi-lumen central 40. Stephens R, Mythen M, Kallis P, Davies DW, Egner W, Rickards
venous catheters in critically ill patients. Crit Care Med A: Two episodes of life-threatening anaphylaxis in the same
2007; 35:10329 patient to a chlorhexidine-sulphadiazine-coated central ve-
25. Bach A, Schmidt H, Bttiger B, Schreiber B, Bhrer H, Motsch J, nous catheter. Br J Anaesth 2001; 87:306 8
Martin E, Sonntag HG: Retention of antibacterial activity and 41. Terazawa E, Shimonaka H, Nagase K, Masue T, Dohi S:
bacterial colonization of antiseptic-bonded central venous Severe anaphylactic reaction due to a chlorhexidine-im-
catheters. J Antimicrob Chemother 1996; 37:31522 pregnated central venous catheter. ANESTHESIOLOGY 1998;
26. Brun-Buisson C, Doyon F, Sollet JP, Cochard JF, Cohen Y, 89:1296 8
Nitenberg G: Prevention of intravascular catheter-related 42. Merrer J, De Jonghe B, Golliot F, Lefrant JY, Raffy B, Barre
infection with newer chlorhexidine-silver sulfadiazine- E, Rigaud JP, Casciani D, Misset B, Bosquet C, Outin H,
coated catheters: A randomized controlled trial. Intensive Brun-Buisson C, Nitenberg G, French Catheter Study Group
Care Med 2004; 30:837 43 in Intensive Care: Complications of femoral and subclavian
27. Ciresi DL, Albrecht RM, Volkers PA, Scholten DJ: Failure of venous catheterization in critically ill patients: A random-
antiseptic bonding to prevent central venous catheter-related ized controlled trial. JAMA 2001; 286:700 7
infection and sepsis. Am Surg 1996; 62:641 6 43. Parienti JJ, Thirion M, Megarbane B, Souweine B, Ouchikhe
28. Collin GR: Decreasing catheter colonization through the use A, Polito A, Forel JM, Marque S, Misset B, Airapetian N,
of an antiseptic-impregnated catheter: A continuous quality Daurel C, Mira JP, Ramakers M, du Cheyron D, Le Coutour
improvement project. Chest 1999; 115:1632 40 X, Daubin C, Charbonneau P, Members of the Cathedia

SPECIAL ARTICLES
Study Group: Femoral vs jugular venous catheterization and DA, Pruett TL, Schwenzer KJ, Farr BM: A controlled trial of
risk of nosocomial events in adults requiring acute renal scheduled replacement of central venous and pulmonary-ar-
replacement therapy: A randomized controlled trial. JAMA tery catheters. N Engl J Med 1992; 327:1062 8
2008;299:241322 59. Eyer S, Brummitt C, Crossley K, Siegel R, Cerra F: Catheter-
44. Collignon P, Soni N, Pearson I, Sorrell T, Woods P: Sepsis related sepsis: Prospective, randomized study of three
associated with central vein catheters in critically ill pa- methods of long-term catheter maintenance. Crit Care Med
tients. Intensive Care Med 1988; 14:22731 1990; 18:10739
45. Gil RT, Kruse JA, Thill-Baharozian MC, Carlson RW: Triple- 60. Kealey GP, Chang P, Heinle J, Rosenquist MD, Lewis RW:
vs single-lumen central venous catheters: A prospective Prospective comparison of two management strategies of
study in a critically ill population. Arch Intern Med 1989; central venous catheters in burn patients. J Trauma 1995;
149:1139 43 38:344 9
46. Gowardman JR, Robertson IK, Parkes S, Rickard CM: Influ- 61. Michel LA, Bradpiece HA, Randour P, Pouthier F: Safety of
ence of insertion site on central venous catheter coloniza- central venous catheter change over guidewire for sus-
tion and bloodstream infection rates. Intensive Care Med pected catheter-related sepsis. A prospective randomized
2008; 34:1038 45 trial. Int Surg 1988; 73:180 6
47. Lorente L, Henry C, Martn MM, Jimenez A, Mora ML: 62. Snyder RH, Archer FJ, Endy T, Allen TW, Condon B, Kaiser
Central venous catheter-related infection in a prospective J, Whatmore D, Harrington G, McDermott CJ: Catheter
and observational study of 2,595 catheters. Crit Care 2005; infection: A comparison of two catheter maintenance tech-
9:R6315 niques. Ann Surg 1988; 208:6513
48. McKinley S, Mackenzie A, Finfer S, Ward R, Penfold J: 63. Casey AL, Burnell S, Whinn H, Worthington T, Faroqui MH,
Incidence and predictors of central venous catheter related Elliott TS: A prospective clinical trial to evaluate the micro-
infection in intensive care patients. Anaesth Intensive Care bial barrier of a needleless connector. J Hosp Infect 2007;
1999; 27:164 9 65:212 8
49. Ramos GE, Bolgiani AN, Patio O, Prezzavento GE, 64. Casey AL, Worthington T, Lambert PA, Quinn D, Faroqui MH,
Guastavino P, Durlach R, Fernandez Canigia LB, Benaim F: Elliott TS: A randomized, prospective clinical trial to assess the
Catheter infection risk related to the distance between potential infection risk associated with the PosiFlow needle-
insertion site and burned area. J Burn Care Rehabil 2002; less connector. J Hosp Infect 2003; 54:288 93
23:266 71 65. Lucet JC, Hayon J, Bruneel F, Dumoulin JL, Joly-Guillou ML:
50. Levy I, Katz J, Solter E, Samra Z, Vidne B, Birk E, Ashkenazi Microbiological evaluation of central venous catheter ad-
S, Dagan O: Chlorhexidine-impregnated dressing for pre- ministration hubs. Infect Control Hosp Epidemiol 2000;
vention of colonization of central venous catheters in in- 21:40 2
fants and children: A randomized controlled study. Pediatr 66. Ybenes JC, Vidaur L, Serra-Prat M, Sirvent JM, Batlle J, Motje
Infect Dis J 2005; 24:676 9 M, Bonet A, Palomar M: Prevention of catheter-related
51. Roberts B, Cheung D: Biopatch: A new concept in antimi- bloodstream infection in critically ill patients using a disin-
crobial dressings for invasive devices. Aust Crit Care 1998; fectable, needle-free connector: A randomized controlled
11:16 9 trial. Am J Infect Control 2004; 32:2915
52. Timsit JF, Schwebel C, Bouadma L, Geffroy A, Garrouste- 67. Kaiser CW, Koornick AR, Smith N, Soroff HS: Choice of
Orgeas M, Pease S, Herault MC, Haouache H, Calvino- route for central venous cannulation: Subclavian or internal
Gunther S, Gestin B, Armand-Lefevre L, Leflon V, Chaplain jugular vein? A prospective randomized study. J Surg Oncol
C, Benali A, Francais A, Adrie C, Zahar JR, Thuong M, 1981; 17:34554
Arrault X, Croize J, Lucet JC, Dressing Study Group: Chlo- 68. Eisenhauer ED, Derveloy RJ, Hastings PR: Prospective eval-
rhexidine-impregnated sponges and less frequent dressing uation of central venous pressure (CVP) catheters in a large
changes for prevention of catheter-related infections in city-county hospital. Ann Surg 1982; 196:560
critically ill adults: A randomized controlled trial. JAMA
2009; 301:1231 41 69. Molgaard O, Nielsen MS, Handberg BB, Jensen JM, Kjaer-
gaard J, Juul N: Routine X-ray control of upper central
53. Madeo M, Martin CR, Turner C, Kirkby V, Thompson DR: A
venous lines: Is it necessary? Acta Anaesthesiol Scand 2004;
randomized trial comparing Arglaes (a transparent dressing
48:6859
containing silver ions) to Tegaderm (a transparent polyure-
thane dressing) for dressing peripheral arterial catheters 70. Sznajder JI, Zveibil FR, Bitterman H, Weiner P, Bursztein S:
and central vascular catheters. Intensive Crit Care Nurs Central vein catheterization: Failure and complication rates
1998; 14:18791 by three percutaneous approaches. Arch Intern Med 1986;
146:259 61
54. Garland JS, Alex CP, Mueller CD, Otten D, Shivpuri C, Harris
MC, Naples M, Pellegrini J, Buck RK, McAuliffe TL, Goldmann 71. Armstrong PJ, Sutherland R, Scott DH: The effect of posi-
DA, Maki DG: A randomized trial comparing povidone-iodine tion and different manoeuvres on the internal jugular vein
to a chlorhexidine gluconate-impregnated dressing for preven- diameter size. Acta Anaesth Scand 1994; 38:229 31
tion of central venous catheter infections in neonates. Pediat- 72. Bellazzini MA, Rankin PM, Gangnon RE, Bjoernsen LP: Ul-
rics 2001; 107:1431 6 trasound validation of maneuvers to increase internal jugu-
55. Moro ML, Vigano ` EF, Cozzi Lepri A: Risk factors for central lar vein cross-sectional area and decrease compressibility.
venous catheter-related infections in surgical and intensive Am J Emerg Med 2009; 27:454 9
care units: The Central Venous Catheter-Related Infections 73. Modeliar SS, Sevestre MA, de Cagny B, Slama M: Ultrasound
Study Group. Infect Control Hosp Epidemiol 1994; 15: evaluation of central veins in the intensive care unit: Effects of
253 64 dynamic manoeuvres. Intensive Care Med 2008; 34:333 8
56. Bonawitz SC, Hammell EJ, Kirkpatrick JR: Prevention of 74. Parry G: Trendelenburg position, head elevation and a mid-
central venous catheter sepsis: A prospective randomized line position optimize right internal jugular vein diameter.
trial. Am Surg 1991; 57:618 23 Can J Anaesth 2004; 51:379 81
57. Kowalewska-Grochowska K, Richards R, Moysa GL, Lam K, 75. Suarez T, Baerwald JP, Kraus C: Central venous access: The
Costerton JW, King EG: Guidewire catheter change in cen- effects of approach, position, and head rotation on internal
tral venous catheter biofilm formation in a burn population. jugular vein cross-sectional area. Anesth Analg 2002; 95:
Chest 1991; 100:1090 5 1519 24
58. Cobb DK, High KP, Sawyer RG, Sable CA, Adams RB, Lindley 76. Tugrul M, Camci E, Pembeci K, Al-Darsani A, Telci L: Relation-

Practice Guidelines
ship between peripheral and central venous pressures in dif- insertion as a temporary hemodialysis access. Ren Fail 2005;
ferent patient positions, catheter sizes, and insertion sites. 27:561 4
J Cardiothorac Vasc Anesthesia 2004; 18:446 50 95. Cajozzo M, Quintini G, Cocchiera G, Greco G, Vaglica R,
77. Sayin MM, Mercan A, Koner O, Ture H, Celebi S, Sozubir S, Pezzano G, Barbera V, Modica G: Comparison of central
Aykac B: Internal jugular vein diameter in pediatric pa- venous catheterization with and without ultrasound guide.
tients: Are the J-shaped guidewire diameters bigger than Transfus Apher Sci 2004; 31:199 202
internal jugular vein? An evaluation with ultrasound Paedi- 96. Grebenik CR, Boyce A, Sinclair ME, Evans RD, Mason DG,
atr Anaesth 2008; 18:74551 Martin B: NICE guidelines for central venous catheterization
78. Brown CQ: Inadvertent prolonged cannulation of the ca- in children. Is the evidence base sufficient? Br J Anaesth
rotid artery. Anesth Analg 1982; 61:150 2 2004; 92:82730
79. Digby S: Fatal respiratory obstruction following insertion of 97. Karakitsos D, Labropoulos N, De Groot E, Patrianakos AP,
a central venous line. Anaesthesia 1994; 49:1013 4 Kouraklis G, Poularas J, Samonis G, Tsoutsos DA, Konsta-
80. Guilbert MC, Elkouri S, Bracco D, Corriveau MM, Beaudoin doulakis MM, Karabinis A: Real-time ultrasound-guided cath-
N, Dubois MJ, Bruneau L, Blair JF: Arterial trauma during eterisation of the internal jugular vein: A prospective com-
central venous catheter insertion: Case series, review and parison with the landmark technique in critical care
proposed algorithm. J Vasc Surg 2008; 48:918 25, discus- patients. Crit Care 2006; 10:R162
sion 925 98. Koroglu M, Demir M, Koroglu BK, Sezer MT, Akhan O,
81. Farhat K, Nakhjavan K, Cope C, Yazdanfar S, Fernandez J, Yildiz H, Yavuz L, Baykal B, Oyar O: Percutaneous place-
Gooch A, Goldberg H: Iatrogenic arteriovenous fistula: A ment of central venous catheters: Comparing the anatomi-
complicaton of percutaneous subclavian vein puncture. cal landmark method with the radiologically guided tech-
Chest 1975; 67:480 2 nique for central venous catheterization through the
internal jugular vein in emergency hemodialysis patients.
82. Kulvatunyou N, Heard SO, Bankey PE: A subclavian artery Acta Radiol 2006; 47:437
injury, secondary to internal jugular vein cannulation, is a
predictable right-sided phenomenon. Anesth Analg 2002; 99. Mallory DL, McGee WT, Shawker TH, Brenner M, Bailey KR,
95:564 6 Evans RG, Parker MM, Farmer JC, Parillo JE: Ultrasound
guidance improves the success rate of internal jugular vein
83. Maschke SP, Rogove HJ: Cardiac tamponade associated with cannulation: A prospective, randomized trial. Chest 1990;
a multilumen central venous catheter. Crit Care Med 1984; 98:157 60
12:6113
100. Slama M, Novara A, Safavian A, Ossart M, Safar M, Fagon JY:
84. Nicholson T, Ettles D, Robinson G: Managing inadvertent Improvement of internal jugular vein cannulation using an
arterial catheterization during central venous access proce- ultrasound-guided technique. Intensive Care Med 1997; 23:
dures. Cardiovasc Intervent Radiol 2004; 27:215 916 9
85. Powell H, Beechey AP: Internal jugular catheterisation: 101. Teichgrber UKM, Benter T, Gebel M, Manns MP: A sono-
Case report of a potentially fatal hazard. Anaesthesia 1990; graphically guided technique for central venous access. AJR
45:458 9 Am J Roentgenol 1997; 169:7313
86. Shah PM, Babu SC, Goyal A, Mateo RB, Madden RE: Arterial 102. Troianos CA, Jobes DR, Ellison N: Ultrasound-guided can-
misplacement of large-caliber cannulas during jugular vein nulation of the internal jugular vein: A prospective, ran-
catheterization: Case for surgical management. Am Coll domized study. Anesth Analg 1991; 72:823 6
Surg 2004; 198:939 44
103. Verghese ST, McGill WA, Patel RI, Sell JE, Midgley FM,
87. Sloan MA, Mueller JD, Adelman LS, Caplan LR: Fatal brain- Ruttimann UE: Comparison of three techniques for internal
stem stroke following internal jugular vein catheterization. jugular vein cannulation in infants. Paediatr Anaesth 2000;
Neurology 1991; 41:10925 10:50511
88. Zaidi NA, Khan M, Naqvi HI, Kamal RS: Cerebral infarct 104. Verghese ST, McGill WA, Patel RI, Sell JE, Midgley FM,
following central venous cannulation. Anaesthesia 1998; Ruttimann UE: Ultrasound-guided internal jugular venous
53:186 91 cannulation in infants: A prospective comparison with the
89. Reeves ST, Roy RC, Dorman BH, Fishman RL, Pinosky ML: The traditional palpation method. ANESTHESIOLOGY 1999; 91:717
incidence of complications after the double-catheter technique 105. Gualtieri E, Deppe SA, Sipperly ME, Thompson DR: Subcla-
for cannulation of the right internal jugular vein in a university vian venous catheterization: Greater success rate for less
teaching hospital. Anesth Analg 1995; 81:1073 6 experienced operators using ultrasound guidance. Crit Care
90. Milling TJ Jr., Rose J, Briggs WM, Birkhahn R, Gaeta TJ, Bove Med 1995; 23:6927
JJ, Melniker LA: Randomized, controlled clinical trial of 106. Fragou M, Gravvanis A, Dimitriou V, Papalois A, Kouraklis G,
point-of-care limited ultrasonography assistance of central Karabinis A, Saranteas T, Poularas J, Papanikolaou J, Davlouros
venous cannulation: The Third Sonography Outcomes As- P, Labropoulos N, Karakitsos D: Real-time ultrasound-guided
sessment Program (SOAP-3) Trial. Crit Care Med 2005; subclavian vein cannulation versus the landmark method in
33:1764 9 critical care patients: A propsective randomized study. Crit
91. Alderson PJ, Burrows FA, Stemp LI, Holtby HM: Use of Care Med 2011; 39:160712
ultrasound to evaluate internal jugular vein anatomy and to 107. Aouad MT, Kanazi GE, Abdallah FW, Moukaddem FH, Tur-
facilitate central venous cannulation in paediatric patients. bay MJ, Obeid MY, Siddik-Sayyid SM: Femoral vein cannu-
Br J Anaesth 1993; 70:145 8 lation performed by residents: A comparison between ul-
92. Hayashi H, Amano M: Does ultrasound imaging before trasound-guided and landmark technique in infants and
puncture facilitate internal jugular vein cannulation? Pro- children undergoing cardiac surgery. Anesth Analg 2010;
spective randomized comparison with landmark-guided 111:724 8
puncture in ventilated patients. J Cardiothorac Vasc Anesth 108. Ezaru CS, Mangione MP, Oravitz TM, Ibinson JW, Bjerke RJ:
2002; 16:5725 Eliminating arterial injury during central venous catheteriza-
93. Mansfield PF, Hohn DC, Fornage BD, Gregurich MA, Ota tion using manometry. Anesth Analg 2009; 109:130 4
DM: Complications and failures of subclavian-vein catheter- 109. Gillman LM, Blaivas M, Lord J, Al-Kadi A, Kirkpatrick W:
ization. N Engl J Med 1994; 331:1735 8 Ultrasound confirmation of guidewire position may elimi-
94. Bansal R, Agarwal SK, Tiwari SC, Dash SC: A prospective nate accidental arterial dilatation during central venous
randomized study to compare ultrasound-guided with non- cannulation. Scand J Trauma 2010; 18:39
ultrasound-guided double lumen internal jugular catheter 110. Gu X, Paulsen W, Tisnado J, He Y, Li Z, Nixon JV: Malpo-

SPECIAL ARTICLES
sition of a central venous catheter in the right main pulmo- after central venous catheter insertion? Am J Respir Crit
nary artery detected by transesophageal echocardiography. Care Med 2001; 164:4035
J Am Soc Echocardiogr 2009; 22:1420 123. Riblet JL, Shillinglaw W, Goldberg AJ, Mitchell K, Sedani
111. Mahmood F, Sundar S, Khabbaz K: Misplacement of a guide- KH, Davis FE, Reynolds HN: Utility of the routine chest
wire diagnosed by transesophageal echocardiography. X-ray after over-wire venous catheter changes. Am Surg
J Cardiothorac Vasc Anesth 2007; 21:420 1 1996; 62:1064 5
112. Sawchuk C, Fayad A: Confirmation of internal jugular guide 124. Weil BR, Ladd AP, Yoder K: Pericardial effusion and cardiac
wire position utilizing transesophageal echocardiography. tamponade associated with central venous catheters in chil-
Can J Anaesth 2001; 48:688 90 dren: An uncommon but serious and treatable condition.
J Pediatr Surg 2010; 45:168792
113. Janik JE, Cothren CC, Janik JS, Hendrickson RJ, Bensard DD,
Partrick DA, Karrer FM: Is a routine chest x-ray necessary 125. Wirsing M, Schummer C, Neumann R, Steenbeck J, Schmidt
for children after fluoroscopically assisted central venous P, Schummer W: Is traditional reading of the bedside chest
radiograph appropriate to detect intraatrial central ve-
access? J Pediatr Surg 2003; 38:1199 202
nous catheter position? Chest 2008; 134:52733
114. Lucey B, Varghese JC, Haslam P, Lee MJ: Routine chest
126. Francis KR, Picard DL, Fajardo MA, Pizzi WF: Avoiding
radiographs after central line insertion: Mandatory postpro-
complications and decreasing costs of central venous cath-
cedural evaluation or unnecessary waste of resources? Car- eter placement utilizing electrocardiographic guidance.
diovasc Intervent Radiol 1999; 22:381 4 Surg Gynecol Obstet 1992; 175:208 11
115. Gebhard RE, Szmuk P, Pivalizza EG, Melnikov V, Vogt C, 127. McGee WT, Ackerman BL, Rouben LR, Prasad VM, Bandi V,
Warters RD: The accuracy of electrocardiogram-controlled Mallory DL: Accurate placement of central venous cathe-
central line placement. Anesth Analg 2007; 104:6570 ters: A prospective, randomized, multicenter trial. Crit Care
116. Abood GJ, Davis KA, Esposito TJ, Luchette FA, Gamelli RL: Med 1993; 21:1118 23
Comparison of routine chest radiograph versus clinician 128. OGrady NP, Alexander M, Burns LA, Dellinger EP, Garland J,
judgment to determine adequate central line placement in Heard SO, Lipsett PA, Masur H, Mermel LA, Pearson ML, Raad
critically ill patients. J Trauma 2007; 63:50 6 II, Randolph AG, Rupp ME, Saint S, Healthcare Infection Con-
117. Amshel CE, Palesty JA, Dudrick SJ: Are chest X-rays mandatory trol Practices Advisory Committee. Guidelines for the preven-
following central venous recatheterization over a wire? Am tion of intravascular catheter related infections. Am J Infect
Surg 1998; 64:499 501; discussion 5012 Control 2011; 39(4 Suppl 1):S134
118. Bailey SH, Shapiro SB, Mone MC, Saffle JR, Morris SE, Barton 129. Marschall J, Mermel LA, Classen D, Arias KM, Podgorny K, An-
RG: Is immediate chest radiograph necessary after central derson DJ, Burstin H, Calfee DP, Coffin SE, Dubberke ER, Fraser
venous catheter placement in a surgical intensive care unit? V, Gerding DN, Griffin FA, Gross P, Kaye KS, Klompas M, Lo E,
Am J Surg 2000; 180:51721; discussion 5212 Nicolle L, Pegues DA, Perl TM, Saint S, Salgado CD, Weinstein RA,
Wise R, Yokoe DS: Strategies to prevent central line-associated
119. Cullinane DC, Parkus DE, Reddy VS, Nunn CR, Rutherford bloodstream infections in acute care hospitals. Infect Control
EJ: The futility of chest roentgenograms following routine Hosp Epidemiol 2008; 29(Suppl 1):S2230
central venous line changes. Am J Surg 1998; 176:2835
130. Institute for Healthcare Improvement: Prevent Central Line
120. Frassinelli P, Pasquale MD, Cipolle MD, Rhodes M: Utility Infections How-to Guide. Cambridge, MA; 2008
of chest radiographs after guidewire exchanges of
131. The Joint Commission Accreditation Program: Hospital: Na-
central venous catheters. Crit Care Med 1998; 26:6115 tional patient safety goals. http://www.jointcommission.
121. Lessnau KD: Is chest radiography necessary after uncom- org/assets/1/6/2011_NPSGs_HAP.pdf. Accessed January 1,
plicated insertion of a triple-lumen catheter in the right 2011
internal jugular vein, using the anterior approach? Chest 132. National Institute for Clinical Excellence: Guidance on the use of
2005; 127:220 3 ultrasound locating devices for placing central venous catheters.
122. Maury E, Guglielminotti J, Alzieu M, Guidet B, Offenstadt G: http://www.nice.org.uk/nicemedia/pdf/49_English_patient.
Ultrasonic examination: An alternative to chest radiography pdf. Accessed September 2012

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Practice Guidelines for Central Venous Access

A Report by the American Society of Anesthesiologists Task

P RACTICE Guidelines are systematically developed rec-

Developed by the American Society of Anesthesiologists Task B. Purposes of the Guidelines

Anesthesiology, V 116 No 3 539 March 2012

Hickman, Quinton, (6) methods of detection or treat- Scientific Evidence

Anesthesiology 2012; 116:539 73 540 Practice Guidelines

Anesthesiology 2012; 116:539 73 541 Practice Guidelines

Anesthesiology 2012; 116:539 73 542 Practice Guidelines

Anesthesiology 2012; 116:539 73 543 Practice Guidelines

Anesthesiology 2012; 116:539 73 544 Practice Guidelines

Anesthesiology 2012; 116:539 73 545 Practice Guidelines

Anesthesiology 2012; 116:539 73 546 Practice Guidelines

Anesthesiology 2012; 116:539 73 547 Practice Guidelines

Anesthesiology 2012; 116:539 73 548 Practice Guidelines

Anesthesiology 2012; 116:539 73 549 Practice Guidelines

Anesthesiology 2012; 116:539 73 550 Practice Guidelines

Appendix 3. Example of a Central Venous Catheterization Checklist

Date: __________________________ Start Time: ________________ End Time: _______________

1. Consent form complete and in chart Exception: Emergent procedure

Anesthesiology 2012; 116:539 73 551 Practice Guidelines

Access via thin-wall needle (confirmation of wire recommended) Ultrasound

15. Transparent Bio-occlusive dressing applied

Anesthesiology 2012; 116:539 73 552 Practice Guidelines

Appendix 4. Example Duties Performed by an Silver-impregnated catheters versus no coating

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Anesthesiology 2012; 116:539 73 554 Practice Guidelines

Table 1. Meta-analysis Summary

Table 2. Consultant Survey Responses*

Percent Responding to Each Item

Anesthesiology 2012; 116:539 73 555 Practice Guidelines

Percent Responding to Each Item

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Percent Responding to Each Item

III. Prevention of mechanical trauma or injury

Anesthesiology 2012; 116:539 73 557 Practice Guidelines

Percent Responding to Each Item

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Table 3. ASA Member Survey Responses*

Percent Responding to Each Item

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Percent Responding to Each Item

13. Please indicate your preferred catheter

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Percent Responding to Each Item

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Percent Responding to Each Item

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Table 4. SPA Member Survey Responses*

Percent Responding to Each Item

1. A chlorhexidine-containing solution should 250 17.2 26.0 31.6* 17.2 8.0

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Table 5. Evidence Summary*

Evidence Consultant ASA Member SPA Member Guideline

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Evidence Consultant ASA Member SPA Member Guideline

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Evidence Consultant ASA Member SPA Member Guideline

Anesthesiology 2012; 116:539 73 566 Practice Guidelines

Date: ____________ Start Time: End Time: _