Conference Lectures

Practice Guidelines for central venous access

Suresh Bhargav
Practice Guidelines for central venous access are systematically developed recommendations by
the American Society of Anesthesiologists (ASA). Several other organizations also have
recommended guidelines for central venous access. The ASA has recommended new Practice
guidelines for central venous access to provide latest updated information and new
recommendations, which have not been previously recommended, by other guidelines. The ASA
Guidelines differ from existing guidelines in view of incorporating the use of bundled techniques,
use of an assistant during catheter placement, and management of arterial injury. The ASA
Guidelines also differ in areas such as insertion site selection (e.g., upper body site), guidance for
catheter placement (e.g., use of real-time ultrasound) and verification of venous location of the
catheter
ASA Practice guidelines are summarized as follows:
Resource Preparation
● Central venous catheterization should be performed in an environment that permits use of
aseptic techniques.
● A standardized equipment set should be available for central venous access.
● A checklist or protocol should be used for placement and maintenance of central venous
catheters.
● An assistant should be used during placement of a central venous Catheter.
Prevention of Infectious Complications
● For immune compromised patients and high-risk neonates, administer intravenous antibiotic
prophylaxis on case-by case basis.
● Intravenous antibiotic prophylaxis should not be administered routinely.
● In preparation for the placement of central venous catheters, use aseptic techniques (e.g., hand
washing) and maximal barrier precautions (e.g., sterile gowns, sterile gloves, caps, masks
covering both mouth and nose, and full-body patient drapes).
● A chlorhexidine-containing solution should be used for skin preparation in adults, infants, and
children.
o For neonates, the use of a chlorhexidine-containing solution for skin preparation should be
based on clinical judgment and institutional protocol.
o If there is a contraindication to chlorhexidine, povidone-iodine or alcohol may be used as
alternatives.
o Unless contraindicated, skin preparation solutions should contain alcohol.
● If there is a contraindication to chlorhexidine, povidone-iodine or alcohol may be used. Unless
contraindicated, skin preparation solutions should contain alcohol.
● Catheters coated with antibiotics or a combination of chlorhexidine and silver sulfadiazine
should be used for selected patients based on infectious risk, cost, and anticipated duration of
catheter use.
o Catheters containing antimicrobial agents are not a substitute for additional infection
precautions.
● Catheter insertion site selection should be based on clinical need.
o An insertion site should be selected that is not contaminated or potentially contaminated (e.g.,
burned or infected skin, inguinal area, adjacent to tracheostomy or open surgical wound).
o In adults, selection of an upper body insertion site should be considered to minimize the risk of
infection.
● The use of sutures, staples, or tape for catheter fixation should be determined on a local or
institutional basis.
● Transparent bio-occlusive dressings should be used to protect the site of central venous catheter
insertion from infection.
o Unless contraindicated, dressings containing chlorhexidine may be used in adults, infants, and
children.
o For neonates, the use of transparent or sponge dressings containing chlorhexidine should be
based on clinical judgment and institutional protocol.
Recommendations for Catheter Maintenance.
● The duration of catheterization should be based on clinical need.
o The clinical need for keeping the catheter in place should be assessed daily.
o Catheters should be removed promptly when no longer deemed clinically necessary.
Recommendations for Aseptic Techniques Using an Existing
Central Line.
● The catheter insertion site should be inspected daily for signs of infection.
o The catheter should be changed or removed when catheter insertion site infection is suspected.
● When a catheter-related infection is suspected, replacing the catheter using a new insertion site
is preferable to changing the catheter over a guidewire.
● Catheter access ports should be wiped with an appropriate antiseptic before each access when
using an existing central venous catheter for injection or aspiration.
● Central venous catheter stopcocks or access ports should be capped when not in use.
● Needle-less catheter access ports may be used on a case-by-case basis.
Prevention of Mechanical Trauma or Injury
Recommendations for Catheter Insertion Site Selection.
● Catheter insertion site selection should be based on clinical need and practitioner judgment,
experience, and skill.
o In adults, selection of an upper body insertion site should be considered to minimize the risk of
thrombotic complications.
Recommendations for Positioning the Patient for Needle Insertion and Catheter Placement
● When clinically appropriate and feasible, central venous access in the neck or chest should be
performed with the patient in the Trendelenburg position.
Recommendations for Needle Insertion, Wire Placement, and Catheter Placement
● Selection of catheter size (i.e., outside diameter) and type should be based on the clinical
situation and skill/ experience of the operator.
o Selection of the smallest size catheter appropriate for the clinical situation should be
considered.
● Selection of a thin-wall needle (a wire-through-thin-wall-needle, or Seldinger) technique versus
a catheter-over-the-needle (a catheter-over-the-needle-then-wire-through-the-catheter, or
Modified Seldinger) technique should be based on the clinical situation and the skill/experience
of the operator.
o The decision to use a thin-wall needle technique or a catheter-over-the-needle 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.
o The catheter-over-the-needle technique may provide more stable venous access if manometry
is used for venous confirmation.
● The number of insertion attempts should be based on clinical judgment.
● The decision to place two catheters in a single vein should be made on a case-by-case basis.
Recommendations for Guidance and Verification of Needle, Wire, and Catheter Placement
● Use static ultrasound imaging in elective situations before prepping and draping for pre-
puncture identification of anatomy to determine vessel localisation and patency when the
internal jugular vein is selected for cannulation.
o Static ultrasound may be used when the subclavian or femoral vein is selected.
● Use real-time ultrasound guidance for vessel localisation and venipuncture when the internal
jugular vein is selected for cannulation.
● Real-time ultrasound may be used when the subclavian or femoral vein is selected.
● Real-time ultrasound may not be feasible in emergency circumstances or in the presence of
other clinical constraints.
● After insertion of a catheter that went over the needle or a thin-wall needle, confirm venous
access.
o Methods for confirming that the catheter or thin-wall needle resides in the vein include, but are
not limited to: ultrasound, manometry, pressure-waveform analysis, or venous blood gas
measurement.
o Blood color or absence of pulsatile flow should not be relied upon for confirming that the
catheter or thin-wall needle resides in the vein.
● When using the thin-wall needle technique, confirm venous residence of the wire after the wire
is threaded.
● When using the catheter-over-the-needle technique, confirmation that the wire resides in the
vein may not be needed
1. when the catheter enters the vein easily and manometry or pressure waveform measurement
provides unambiguous confirmation of venous location of the catheter, and
2. when the wire passes through the catheter and enters the vein without difficulty.
o If there is any uncertainty that the catheter or wire resides in the vein, confirm venous residence
of the wire after the wire is threaded. Insertion of a dilator or large-bore catheter may then
proceed.
o Methods for confirming that the wire resides in the vein include, but are not limited to surface
ultrasound (identification of the wire in the vein) or trans-esophageal echocardiography
(identification of the wire in the superior vena cava or right atrium), continuous
electrocardiography (identification of narrow-complex ectopy), or fluoroscopy.
● After final catheterization and before use, confirm residence of the catheter in the venous
system as soon as clinically appropriate.
o Methods for confirming that the catheter is still in the venous system after catheterization and
before use include Waveform manometry or pressure measurement.
● Confirm the final position of the catheter tip as soon as clinically appropriate.
o Methods for confirming the position of the catheter tip include chest radiography, fluoroscopy,
or continuous electro cardiography.
● For central venous catheters placed in the operating room, perform the chest radiograph no
later than the early postoperative period to confirm the position of the catheter tip.
Management of Arterial Trauma or Injury Arising from Central Venous Catheterization
● When unintended cannulation of an arterial vessel with a dilator or large-bore catheter occurs,
the dilator or catheter should be left in place and a general surgeon, a vascular surgeon, or an
interventional radiologist should be immediately consulted regarding surgical or nonsurgical
catheter removal for adults.
o For neonates, infants, and children, the decision to leave the catheter in place and obtain
consultation or to remove the catheter non surgically should be based on practitioner judgment
and experience.
● After the injury has been evaluated and a treatment plan has been executed, the anesthesiologist
and surgeon should confer regarding relative risks and benefits of proceeding with the elective
surgery versus deferring surgery for a period of- patient observation.
Example of a Standardized Equipment Cart for Central
Venous Catheterization for Adult Patients
Item Description Quantity
First Drawer
Bottles Alcohol-based Hand Cleanser 2
Transparent bio-occlusive dressings with
catheter 2
stabilizer devices
Transducer kit: NaCL 0.9% 500 ml bag;
single- 1
line transducer, pressure bag
Needle Holder, Webster Disposable 5 inch 1
Scissors, 4 1/2 inchSterile 1
Vascular Access Tray(Chloraprep, Sponges, 1
Labels)
Disposable pen with sterile labels 4
Sterile tubing, arterial line pressure-rated
(for 2
manometry)
Intravenous connector with needleless
valve 4
Second Drawer
Ultrasound Probe Cover, Sterile 3 96 2
Applicator, chloraprep 10.5 ml 3
Surgical hair clipper blade 3
Solution, NaCl bacteriostatic 30 ml 2
Third Drawer
Cap, Nurses Bouffant 3
Surgeon hats 6
Goggles 2
Mask, surgical fluidshield 2
Gloves, sterile sizes 6.0–8.0 (2 each size) 10
Packs, sterile gowns 2
Fourth Drawer
Drape, Total Body (with Femoral Window) 1
Sheet, central line total body (no window) 1
Example Duties Performed by an Assistant for Central Venous Catheterization
• Reads prompts on checklist to ensure that no safety step is forgotten or missed. Completes checklist as task is
completed
• Verbally alerts anesthesiologist if a potential error or mistake is about to be made.
• Gathers equipment/supplies or brings standardized supply cart.
• Brings the ultrasound machine, positions it, turns it on, makes adjustments as needed.
• Provides moderate sedation (if registered nurse) if needed.
• Participates in “time-out” before procedure. Washes hands and wears mask, cap, and nonsterile
gloves (scrubs or cover gown required if in the sterile envelope).
• Attends to patient requests if patient awake during procedure.
• Assists with patient positioning. Assists with draping.
• Assists with sterile field setup; drops sterile items into field as needed.
• Assists with sterile ultrasound sleeve application to ultrasound probe.
• Assists with attachment of intravenous lines or pressure lines if needed.
• Assists with application of a sterile bandage at the end of the procedure.
• Assists with clean-up of patient, equipment, and supply cart; returns items to their proper location.