2020 Practice Guide for Central Venous Access

2020 Practice Guide for Central Venous Access

Latest report by the American Association of Anesthesiologists Task Force on Central Venous Access

Severe Patient Translation Group

Kang De, Ning Yile, Yang Mei, Cheng Kang, Hui Xia, He Aiting, Li Ning, Shan Keji, Zhang Jian, Liu Gang, Bian Yuyao, Wang Bo, Jiang Jie, Liang Yan Translation

Bian Yuyao proofreads

Practice guidelines are systematically developed recommendations to assist physicians and patients in making decisions
about health care.
These recommendations may be adopted, modified or rejected based on clinical needs and constraints, but are not intended to replace local institutional policies
.
In addition, the practice guidelines developed by the American Association of Anesthesiologists (ASA) are not intended as standard or absolute requirements, and their use cannot guarantee any particular outcome
.
The Practice Guide is revised
in light of developments in medical knowledge, technology and practice.
They provide basic recommendations and are supported
by synthesis and analysis of the current literature, expert and physician opinions, public forum comments and clinical feasibility data.

This document updates the "Practice Guide to Central Venous Access: Report of the American Association of Anesthesiologists on Central Venous Access," adopted in 2011 and published in 2012
.

method

Definition of central venous access

In these guidelines, central venous access is defined as the placement of a catheter that inserts a catheter into a large vein ve
Intravenous macrovessels include superior vena cava, inferior vena cava, cephalobrachial vein, internal jugular vein, subclavian vein, iliac vein, and common femoral vein
.
Catheters
terminated in systemic circulation arteries are not included.

Purpose of the guide

The objectives of these guidelines are: (1) to provide guidance on the placement and management of central venous catheterization, (2) to reduce the infectious, mechanical, thrombotic and other adverse consequences associated with central venous catheterization, and (3) to improve the management
of arterial trauma or injury caused by central venous catheterization.

focus

These guidelines apply to patients who undergo elective central venous puncture performed by an anesthesiologist or healthcare professional under the guidance/supervision of an
anesthesiologist 。 The guidelines do not state (1) clinical indications for the placement of a central venous catheter; (2) Emergency placement of central venous catheter; (3) Patients with central venous catheterization through peripheral venous puncture; (4) Placement and retention of pulmonary artery ducts; (5) Tunneled central catheters (e.
g.
, permacaths hemodialysis catheters, portacaths infusion port - surgical insertion catheters, Hickman catheters with polyester sleeves, Quinton hemodialysis catheters); (6) Methods of detection or treatment of infectious complications associated with central venous catheterization; (7) Removal of a central venous catheter (although these guidelines do not address catheter removal (usually not usually performed by an anesthesiologist), the risk of venous air embolism after catheter removal is a serious problem
.
The recommendations to minimize such risks are: increase central venous pressure during and immediately after extubation and follow clear nursing protocols
.
These recommendations include, but are not limited to, placing the patient in the Trendelenburg position, using the Valsalva maneuver, applying direct pressure to the puncture site, using an air-blocking dressing, and monitoring the patient for a reasonable period of time after extubation); (8) Diagnosis and management of trauma or injury (e.
g.
, pneumothorax or air embolism) related to the central venous catheter, except for carotid artery injury; (9) Treatment of catheter-related thrombosis; (10) Assessment
of central venous catheterization capacity.

apply

These guidelines are intended for use
by anesthesiologists and individuals under the supervision of an anesthesiologist.
They can also serve as resources for other physicians (e.
g.
, surgeons, radiologists), nurses, or healthcare providers who manage patients with central intravenous catheters
.

Member of the Task Force

The original guidelines were developed by 12 task forces appointed by the American Anesthesiology Society, including private and academic practicing anesthesiologists from different parts of the United States, and two methodologists
from the ASA Standards and Practice Parameters Committee.
In 2017, the ASA Standards and Practice Parameters Committee requested that these guidelines
be updated.
This update was revised by 7 task forces appointed by the ASA, including 5 anesthesiologists and 2 methodologists
.
All Task Force members have published and managed current or potential financial and other conflicts of interest documents
related to the Practice Guide.

Treatment and evaluation of evidence

These new guidelines were developed through a
five-step process.
First, there was a consensus
on the standard of evidence.
Second, original published articles from peer-reviewed journals related to perioperative management of central venous catheters were evaluated and added to the
literature of the original guidelines.
Third, consultants with expertise or interest in central venous catheterization and who practice or work in various settings (e.
g.
, private practice and academic practice) are required to participate in opinion surveys to determine the appropriateness, completeness and feasibility of implementing the draft recommendations, and to review and comment on the draft
guidelines.
Fourth, solicit additional comments
from a random selection of active ASA members.
Fifth, build consensus using all available information to finalize guidance guidelines
.

The designation of these latest guidelines follows strict system processes
.
Evidence comes from two main sources: scientific evidence and opinion-based evidence
.
A detailed description of the ASA processes and methods used in these guidelines can be found
in other relevant publications.
Appendix 1 of 2-5 contains a footnote describing the evidence model, literature search process, literature finding, and sources of information for
these guidelines.

In the text of these guidelines, the literature classification for each intervention was reported using the following methodology: Meta-analysis of Class A Level 1, Randomized Controlled Trials (RCTs); Class A level 2, multiple randomized controlled trials; Class A grade 3, single randomized controlled trial; Class B level 1, non-randomized studies with grouped comparisons; Class B Level 2, non-randomized studies with relevant findings; Class B Level 3, non-randomized studies with descriptive results; Category B Level 4, Case Series or Case Report
.
Statistically significant results (P<0.
01) are designated as beneficial to the patient (B) or harmful (H); Statistically insignificant findings are designated as ambiguous (E).

In the body of these guidelines, the results
of a randomly sampled survey of expert consultants appointed by task forces and ASA members are reported in full.
Based on the median from strong agreement to strong objection, a five-point scale is used to report feedback on each recommendation
.

Guide recommendations

Preparation of environmental goods and resources

The topics of resource preparation include (1) assessing the external physical environment of the planned central venous catheter to determine the feasibility of using sterile techniques; (2) Confirm that there are standardized accessories and equipment; (3) Use the process list or protocol to guide the placement and maintenance of the central venous catheter; (4) Assistant participates in the assistance during central venous catheterization
.

Literature evidence: the literature is insufficient to evaluate the effect
of the physical environment of sterile catheterization, the availability of equipment for standardized fittings, or the involvement of assistants on the prognosis associated with central venous catheterization.
One observational study reported that the trauma ICU implemented a multidisciplinary list list system, which was associated with a decreased incidence of catheter-associated
infections.
Observational studies have reported a decrease in the incidence of central venous or catheter-associated bloodstream infections following the widespread implementation of a clustering protocol within the ICU; Results from a small number of observational studies are ambiguous; Other observational studies did not report statistical differences or lacked data to calculate
.
These studies failed to assess the effect of a single portion of a process list or cluster protocol on
infection rates.

Findings: Respondents and ASA members strongly agree with recommendations for central venous catheterization in sterile settings and the use of standard accessory equipment for central venous access
.
Respondents strongly agree, and ASA members agree with recommendations regarding the use of process lists or protocols to place and maintain central venous catheters
.
Respondents and ASA members agreed on recommendations regarding the involvement of assistants in the placement of central venous catheters
.

Recommendations for the preparation of environmental goods and resources

 Implementation of central venous catheterization in an environment where sterile techniques can be implemented; Ensure that standard accessories and equipment available for central venous access are available; Use a process list or protocol for the placement and maintenance of a central venous catheter; A central venous catheter is inserted with an assistant involved
.

Prevention of infectious complications

Interventions for the prevention of infection complications associated with intravenous access in the center include, but are not limited to, (1) intravenous antimicrobial prophylaxis; (2) sterile preparation of operators, staff, and patients; (3) choice of antimicrobial solutions; (4) selection of antimicrobial catheters; (5) selection of catheter puncture sites; (6) catheter fixation methods; (7) puncture site dressings; (8) catheter maintenance procedures; and (9) sterile techniques
for central venous catheter injection or aspiration.

Intravenous antibiotics for prophylaxis

Literature outcomes: the available literature is insufficient to assess the results
associated with routine intravenous prophylactic antibiotics.

Findings: Experts and members of the American Association of Anesthesiologists also do not recommend routine intravenous prophylactic antibiotics
.

Sterile preparation for doctors, staff and patients

Literature Results: One randomized controlled trial compared the unclear results of maximized barrier prophylaxis measures (e.
g.
, masks, hats, gloves, gowns, large systemic procedures) and control groups (e.
g.
, gloves and small procedures) in reducing colonization and catheter-associated sepsis (A3-E evidence).

A large number of observational studies or studies with computable levels of statistical significance have reported that bundled sterile protocols (e.
g.
, hand washing, systemic coverage of sterile procedures, sterile gloves, sterile caps, and masks) reduce the frequency of central vein-related or catheter-associated bloodstream infections (B2-B evidence).

These studies were unable to assess the effect of any single component in a bundled protocol on the probability of
infection.

Findings: The panel and members of the American Society of Anesthesiologists strongly recommend that sterile techniques (e.
g.
, hand washing) and maximum protective measures (e.
g.
, sterile gloves, hats, masks covering the nose and mouth, and systemic sterile procedures)
should be used before inserting a central venous catheter.

Choice of disinfectant

Literature Results: A randomized controlled study comparing chlorhexidine (2% aqueous solution, no alcohol) and povidone iodine (10%, alcohol-free) for skin preparation reported unclear results in catheter colonization and catheter-associated bacteremia (class A3-E evidence).

。 A randomized controlled trial (RCT) comparing chlorhexidine (2% with 70% isopropanol) with povidone iodine (5% with 69% ethanol) and whether to scrub the skin prior to sterilization found that patients in the chlorhexidine group had a low probability of catheter colonization (class A3-B evidence), while the evidence for whether chlorhexidine reduces catheter-associated bloodstream infection is unclear (A3-E evidence).

。 A third randomized controlled trial compared two chlorhexidine concentrations (0.
5% or 1.
0% concentration, 79% ethanol) and povidone iodine (10% alcohol-free) and reported unclear
evidence for colonization (evidence of class A3-E) and catheter-associated bloodstream infection (class A3-E evidence).
One quasi-experimental study (secondary analysis of RCTs) reported lower catheter-associated bloodstream infections (class B1-B evidence) of chlorhexidine (2%, 70% alcohol) than povidone iodine (5%, 69% alcohol).

The current literature is insufficient to evaluate the safety
of chlorhexidine disinfectant solutions in newborns, infants and children.

Current comparative studies are insufficient to evaluate the effect
of alcoholic chlorhexidine versus alcohol-free chlorhexidine on skin preparation during central venous catheterization.
Randomized controlled trials of 5% povidone iodine containing 70% alcohol versus 10% povidone iodine alone showed that the use of alcoholic solutions reduced colonization of catheter tips (class A3-B evidence); Catheter-associated bloodstream infection and signs of clinical infection are unclear (A3-E evidence).

Findings: The expert group and members of the American Association of Anesthesiologists strongly recommend the use of chlorhexidine solutions
in the preparation of skin in adults, infants, and children.
The use of chlorhexidine solution for skin preparation in newborns is recommended by the panel and members of the American Association of Anesthesiologists based on clinical judgment and institutional protocol
.
If the patient has contraindications to chlorhexidine, the expert group strongly recommends that members of the American Association of Anesthesiologists recommend the use of povidone iodine or alcohol
.
Unless there are contraindications to use, the expert group and members of the American Association of Anesthesiologists recommend the use of alcohol-based preparation solutions for skin preparation
.

Antibiotic-coated catheter

Literature findings: Meta-analysis of randomized controlled studies showed that antibiotic-coated catheters were associated with pathogenic colonization of catheters and a reduction in catheter-associated bloodborne infections compared with uncoated catheters (Class A1-B evidence).

Meta-analyses of randomized controlled studies compared silver or silver-platinum carbon-coated catheters with uncoated catheters with uncertain results (class A1-E evidence) but a reduced risk of catheter-associated blood-borne infection (class A1-B evidence).

Meta-analysis of randomized controlled studies showed that chlorhexidine or sulfadiazine silver-coated catheters reduced catheter colonization (class A1-B evidence) compared with uncoated catheters, but the results for catheter-associated bloodstream infection were uncertain (class A1-E evidence).

There have also been reports
of anaphylactic shock after the insertion of chlorhexidine or sulfadiazine silver coated catheters.
(Class B4-H evidence).

Findings: Both the Advisory Board and ASA members agreed to use catheters containing antibiotics or silver chlorhexidine and sulfadiazine coatings, depending on the risk of infection and the estimated timing of catheterization
.
Both the Advisory Board and ASA members fully agree that additional infection precautions should not be replaced by antibiotic-containing catheters
.

Selection of the place where the catheter is placed

Literature findings: A randomized controlled study comparing the subclavian vein and femoral vein puncture showed that the catheter pathogen colonization rate of femoral venous puncture was higher (class A2-H evidence); However, the outcome of catheter-associated sepsis or catheter-associated bloodstream infection is unclear (A2-E evidence).

One randomized controlled study found that catheter pathogen colonization rates for internal jugular venous puncture were higher than those of the subclavian vein (class A3-H evidence), while femoral venous catheterization had a higher rate of catheter pathogen colonization than the internal jugular vein (class A3-H evidence); However, the evidence for catheter-associated bloodstream infection was unclear in each group (A3-E evidence).

A nonrandomized controlled study in patients with burns reported a higher
incidence of catheter colonization and catheter-associated bloodstream infection in the catheter at the partial position tube adjacent to the burn.
(Class B1-H evidence).

Findings: Both the Advisory Board and ASA members fully agree with the following recommendations: (1) Determine the catheter site according to clinical needs; (2) The puncture point cannot select areas where contamination or potential contamination is present (e.
g.
, burned or infected skin, groin area, tracheostomy or area adjacent to open surgical wounds); (3) Adult catheterization should choose the upper body as much as possible to reduce the risk of
infection.

Catheter fixation

Literature findings: The literature is insufficient to assess whether the use of sutures, sutures, or tape to hold the catheter in place is associated with a higher risk of catheter-associated
infection.

Findings: Both the Advisory Board and ASA members fully endorse the use of stitches, stitchers or tape to secure the catheter
on a local or institutional basis.
Both the Advisory Board and the ASA members are fully in favour of minimizing the number of skin punctures
.

Dressing for the puncture site

Literature findings: The literature is insufficient to assess the effectiveness of transparent closed biodressings in reducing the risk of
infection.
Pooled results from randomized controlled trials suggest that catheter colonization of chlorhexidine sponge dressings is lower than standard polyurethane dressings (class A1-B evidence), but the results of catheter-associated bloodstream infections are unclear (class A1-E evidence).

One randomized controlled study showed that the frequency of severe contact dermatitis in neonates with chlorhexidine impregnating excipients was higher than that of povidone iodine impregnation excipients (class A3-H evidence); However, the results of randomized controlled studies of dermatitis in adults are unclear (A3-E evidence).

Findings: Both the Advisory Board and ASA members fully endorsed the use of transparent enclosed bioexcipients to protect the puncture point of the central venous catheter from infection
.
Both the Advisory Board and ASA members endorse the use of chlorhexidine dressings in adults, infants and children, unless contraindications
exist.
For newborns, both the Advisory Board and ASA members agree to decide on the use
of chlorhexidine-containing transparent excipients or sponge dressings based on clinical judgment and the medical institution's protocol.
When using chlorhexidine excipients, the Advisory Board and ASA members are fully in favor of daily observation of puncture points for irritation, allergies or necrosis
.

Catheter maintenance

Catheter maintenance includes (1) determining the optimal catheter placement time, (2) performing catheter position checks, (3) replacing catheters regularly, and (4) replacing catheters with guide wires instead of choosing a new insertion location
.

Literature findings: Non-randomized controlled studies have shown that long-term catheterization is associated with higher catheter colonization rates, infection, and sepsis (class B1-H evidence).

The literature is insufficient to assess whether the time interval at which the catheter site is examined is associated
with the risk of catheter-related infection.
Randomized controlled trials reported that the catheter was replaced every 3 or 7 days, with no definitive difference in the incidence of catheter tip colonization (class A2-E evidence).

Randomized controlled trials reported no clear difference in the incidence of catheter tip colonization when replacing catheters in situ with guide wires compared with reselecting catheter sites (class A2-E evidence).

Findings: Consultants and ASA members strongly agree with the following recommendations: (1) Determine the timing of placement based on clinical needs; (2) Assess the need for clinical daily retention of catheters; (3) Remove the catheter immediately when it is no longer needed clinically; (4) Check the catheter insertion site daily for signs of infection; (5) Replace or remove the catheter when infection at the insertion site of the catheter is suspected; (6) When catheter-related infection is suspected, replace the catheter with a new insertion site instead of replacing the catheter through the guide
wire.

Sterile technique for injection or aspiration using an existing central venous catheter

Aseptic techniques for injection or aspiration using existing central venous catheters include: (1) cleaning ports with appropriate antimicrobials, (2) covering cap plugs or interfaces, and (3) using needleless catheter connectors or interfaces
.

Literature findings: The literature is insufficient to assess whether cleaning the port or covering the cap plug with an existing central venous catheter for injection or aspiration reduces the risk of
catheter-associated infection.
Randomized controlled trials comparing needleless connectors with standard caps showed low rates of microbial contamination through a cap plug with a needleless connector (class A2-B evidence), but there was no definitive difference in results (due to both) of catheter-associated bloodstream infection (class A2-E evidence).

Findings: Consultants and ASA members strongly recommend that appropriate antimicrobial agents (such as alcohol) be given to clean the catheter interface prior to each injection or aspiration using an existing central venous catheter, and that the central venous catheter cover plug or interface
be covered when no central venous catheter is used.
Consultants and ASA members agree to use needleless catheter interfaces
on a case-by-case basis.

Recommendations for the prevention of infection-related complications

Prophylactic use of intravenous antibiotics

Intravenous antibiotics are not routinely used to prevent infection

Sterile preparation

Adhere to sterile principles (e.
g.
, hand washing) and maximum sterile barrier protection before performing central venous catheter placement (e.
g.
, sterile surgical gowns, sterile gloves, cap, sterile treatment sheet capable of covering the patient's entire body, mask covering the mouth and nose, goggles)

Choice of disinfectant

Use of chlorhexidine solutions for skin disinfection for adults, infants and children; If it is a newborn, it is necessary to choose whether to use chlorhexidine solution for skin disinfection according to clinical judgment and the regulations of the medical institution to which it belongs; If there are contraindications to the use of chlorhexidine solution, povidone iodine or alcohol can be selected for skin disinfection; If there are no contraindications, choose a skin disinfectant
containing alcohol.

Catheter containing antimicrobial coating

For specific patients, depending on their risk of infection and the timing of catheter placement, choose to use catheters containing antimicrobial, chlorhexidine and sulfadiazine silver or silver platinum carbon impregnated coatings; The use of antimicrobial-coated catheters is not a substitute for other infection prevention measures
.

Selection of catheter site

Selection of appropriate catheterization sites according to clinical needs: selection of sites with no infection and potential risk of infection (e.
g.
, burned or infected skin, inguinal area, tracheostomy or near surgically open wounds); Adult patients try to choose the puncture site of the upper body to minimize the risk of
infection.

Fixing of the catheter

According to the local conditions of the puncture site, choose sutures, suture nails or tape for fixation; Minimize the number
of punctures on the skin.

Choice of dressing

Cover the puncture site with a transparent compress with a bio-blocking effect to avoid infection; If there are no contraindications to use, adults, children and infants should choose dressings containing chlorhexidine; If it is a newborn, according to clinical judgment and the regulations of the medical institution to which it belongs, choose a transparent dressing containing chlorhexidine or a sponge dressing; If a dressing containing chlorhexidine is chosen, local irritation, allergies, or necrosis need to be observed daily
.

Catheter maintenance

Decide on the timing of catheter retention according to clinical needs; Daily assessment of the clinical need for retention of catheters; Daily inspection of the puncture site for signs of infection; Promptly remove or replace the catheter when infection at the site of the puncture is suspected; When infection is suspected, the catheter needs to be re-punctured instead of replacing the catheter
with a guide wire.

Sterile technique of applying an existing central venous catheter for injection or aspiration

When performing injection or aspiration operations, the access port of the catheter should be cleaned with an appropriate disinfectant (such as alcohol) before each operation; When not in use, the central venous catheter should be kept closed (cover the central venous catheter plug or closed port); Needle-free catheters can be used as appropriate on a case-by-case basis

Prevention of mechanical trauma or injury

Interventions for mechanical trauma or injury related to intravenous access to prevention centers include, but are not limited to: (1) choice of catheter placement location; (2) Positioning of needle entry and catheterization; (3) needle advance, guide wire and catheter; (4) The guidance of needle advance, guide wire and catheter; (5) Verification
of the position of the needle, guide wire and catheter.

Selection of the place where the catheter is placed

Literature findings: results of randomized controlled trials comparing subclavian and femoral venous catheterization showed that in adult patients, femoral venous catheterization had a higher risk of thrombotic complications (A2-level H); Studies comparing subclavian and internal jugular catheterization have shown a higher risk of thrombosis in internal jugular venous catheterization (class A3-H evidence).

However, the comparison of femoral and internal jugular vein catheterization is inconclusive (A3-E evidence).

In terms of puncture success, randomized controlled trials comparing the internal jugular vein with the subclavian vein showed that the puncture success rate was inconclusive (A2-E evidence).

The same results were found comparing the femoral vein with the subclavian vein (class A2-E evidence); The conclusion is the same as that of the femoral vein compared with the internal jugular vein catheter (class A3-E evidence).

Randomized controlled trials of mechanical complications (notably arterial injury, hematoma, and pneumothorax) have shown that the comparison of femoral vein and subclavian venous catheterization is inconclusive (A2-E evidence), as well as intracervical and subclavian or femoral vein catheterization (A3-E evidence).

Findings: In terms of catheter placement, investigators and ASA members strongly endorse the determination of catheter placement based on clinical needs and physician judgment, experience, and skills
.
At the same time, due to the high risk of thrombosis of femoral vein catheterization, the idea of choosing a superior body position catheter (i.
e.
, subclavian vein or internal jugular vein) is also strongly recognized
.

Patient positioning for needle insertion and catheter placement

Literature findings: Although observational studies have reported that Trendelenburging increases the diameter or cross-sectional area of the right internal jugular vein in adult volunteers (B2-B evidence), the results of studies on the recruitment of adult patients are uncertain (B2-E evidence).

。 The literature compared observational studies of the Trondrenburg and supine positions in pediatric patients and reported an increase in the diameter or cross-sectional area of the right internal jugular vein (class B2-B evidence), and similar results
were reported in the literature and one observational study in neonates.

Findings: Consultants and ASA members unanimously strongly recommend that patients undergo a central venous puncture
in the neck or chest using the Trendelenburg position where clinically appropriate and feasible.

Puncture, placement of guide wires and catheter placement

Puncture, placement of guide wires and catheter placement: (1) selection of catheter size and type; (2) Using the thin-walled puncture needle technique that the guide wire can pass through (i.
e.
, Seldinger technique), or using a puncture needle with a sheathed tube, the puncture needle is removed after the puncture is successful, the sheath tube is left in the vascular cavity, and then the catheter is placed on the guide wire (i.
e.
, the modified Seldinger technique); (3) limit the number of insertion attempts; and (4) two catheters
inserted in the same central vein.

Findings in the literature: The case report describes severe injuries (eg, bleeding, hematoma, pseudoaneurysm, arteriovenous fistula, arterial dissection, nerve injuries including stroke, and severe or fatal airway obstruction) with a large-bore catheter (class B4-H evidence).

。 An RCT comparing the application of thin-walled needle puncture with sheath needle puncture technique in adults in right side of the jugular vein insertion in adults, reporting uncertain outcomes of first-time success and complication rate (A3-E evidence); For right subclavian venipuncture in adults, RCT reports that first-time attempts using thin-walled needle aspiration (i.
e.
, Seldinger technique) have a higher success rate and fewer complications (Class A3-B evidence).

One RCT reported that the success and complication rates of the first attempt were also uncertain when comparing the thin-walled needle puncture technique (i.
e.
, Seldinger technique) with the sheath needle puncture technique (modified Seldinger technique) for internal jugular venipuncture (preferentially right
).
In neonates (class A3-E evidence), observational studies reported a higher frequency of complications with an increase in the number of puncture catheterization attempts (class B3-H evidence
).
A non-randomized comparative study reported a higher frequency of arrhythmias when placing two central venous catheters in the same vein (right internal jugular vein) compared to placing one catheter in a vein (class B1-H evidence); However, no differences in carotid artery puncture or hematoma were found (class B1-E evidence
).

Surveys have shown: Consulting physicians and ASA members strongly endorse recommendations
for selecting the size (i.
e.
, outside diameter) and type of catheter based on clinical circumstances and the operator's skills/experience 。 The consulting physician and ASA member agree with the following recommendations: (1) choose a catheter of the smallest size suitable for the clinical situation; (2) Choose thin-walled needle (i.
e.
Seldinger) technology and sleeve needle (i.
e.
modified Seldinger) technology; (3) According to the clinical situation and the operator's skills/experience, select thin-walled needle or cannula needle technology for neck or thigh access; (4) The decision to use thin-walled needle technique or casing needle technique is at least partly based on the method of confirming that the wire is in the vein before the dilator or large-diameter catheter is penetrated
.
The consulting physician and ASA members strongly agree that the number of insertions should be based on clinical judgment and that the decision to place two catheters in one vein should depend on the specific circumstances
.

Placement of puncture needles, guide wires and catheters

Needle placement, guide wire and catheter placement includes: (1) real-time or dynamic ultrasound for vascular positioning and guiding the needle to a predetermined venous location; (2) Static ultrasound imaging is used for the localization
of blood vessels before puncture.

Literature findings: Meta-analysis of RCT comparing intrajugular venous puncture with anatomical markers guided by real-time ultrasound showed that the success rate and overall success rate of first puncture were higher
.
Arterial puncture rates are lower and fewer punctures (Class A1-B evidence
).
RCTs also showed that the use of ultrasound reduced catheter time or number of catheterization (class A2-B evidence)
compared with anatomical markers.
For the subclavian vein, RCTs reported fewer real-time ultrasound-guided venipuncture attempts (A2-B evidence) and a high overall success rate (A2-B evidence
).
The results of arterial puncture and hematoma are unclear compared to anatomical markers (class A2-E evidence).

In the case of the femoral vein, one RCT reported a higher first-time success rate and fewer injections of intravenous puncture under real-time ultrasound compared to anatomy markers in pediatric patients (A3-B evidence).

A meta-analysis of RCTs comparing static ultrasound with anatomical markers yielded ambiguous evidence of improved overall success rate of internal jugular venous insertion (A1-E evidence), independent of the placement site (A1-E evidence), or an effect on arterial puncture rate (A1-E evidence).

Comparing RCT reports comparing static ultrasound with anatomical markers to localize the internal jugular vein, the success rate of first insertion of static ultrasound was higher (class A3-B evidence).

The overall success rate of the subclavian venous access (A3-E evidence) or femoral venous access compared with anatomical markers (A3-E evidence) is unclear
in the literature.

Investigations have shown: Consulting physicians and ASA members strongly endorse the recommendation
to use real-time ultrasound guidance for vascular localization and venipuncture when selecting an internal jugular venous catheterization.
Consulting physicians and ASA members agree that real-time ultrasound
may be used when selecting the subclavian or femoral veins where feasible.
The consulting physician strongly agrees, and the ASA members also endorse, that when choosing an internal jugular vein intubation, static ultrasound imaging is used before preparing and disinfecting the sheet to determine the location and patency of
the blood vessels.
Consulting physicians and ASA members agree that static ultrasound
may also be used when selecting the subclavian or femoral veins.

Confirm pin, guide wire, and catheter placement

Verification of needle, wire, and catheter placement includes (1) confirmation that the catheter or thin-walled needle is in the vein, (2) confirmation that the catheter is in the vein, and (3) confirmation of the catheter position in the venous system and the final catheter
tip.
(Verification methods for needle, wire guide, or catheter placement may include any one or more of the following: ultrasound, manometry, pressure-waveform analysis, venous blood gas, fluoroscopy, continuous ECG, transesophageal echocardiogram, and chest x-ray
.
) ）

Literature findings: A retrospective observational study reported that manometry can detect arterial puncture (class B3-B evidence)
with unrecognized blood flow and blood color.
There is insufficient
literature on ultrasound, pressure waveform analysis, blood gas analysis, and blood-colored or non-pulsating blood flow as effective methods for confirming venous access to catheters or thin-walled needles.
Two observational studies have shown that ultrasound can confirm whether the guide wire is located in a vein before dilation or final catheter insertion (class B3-B evidence).

Observational studies have also confirmed that transthoracic echocardiography confirms the presence of the guide filament in the venous system (class B3-B evidence).

One observational study showed that transesophageal echocardiography could be used to identify guide filament locations (class B3-B evidence) and that case reports documented similar results (class B4-B evidence
).
Observational studies have shown that transthoracic ultrasound confirms proper catheter tip position (class B2-B evidence
).
(Transthoracic ultrasound has also been reported to be highly specific for excluding pneumothorax
.
) These studies were controlled using chest x-rays
.
Observational studies have also shown that fluoroscopy and chest x-ray can identify the location of the catheter (class B2-B evidence
).
RCT studies comparing with non-ECG-guided catheter placement have shown that continuous ECG guidance is more effective in identifying proper catheter tip placement (class A2-B evidence).

The case report documented complications from unidentified stranded guide wires, including embolism and rupture, infection, arrhythmias, cardiac perforation, stroke, and displacement of the guide wire through soft tissues (class B-4H evidence).

Surveys have shown that consultants and ASA members strongly agree with the recommendation to confirm venous access after inserting a catheter with a needle with a catheter (the needle is like an arterial puncture needle, with the needle inside and the catheter wrapped around the needle) and the recommendation
that the catheter or thin-walled needle remain in the vein without blood color or pulsating blood flow.
The consultant strongly agreed, and the ASA members also agreed with the recommendation
to confirm that the guide wire is in the vein after it has passed through the thin-walled needle.
(1) If the catheter easily enters the vein, manometry or pressure waveform measurement can clearly confirm the venous location of the catheter, and (2) if the catheter successfully passes through the catheter and enters the vein, consultants disagree, and ASA members agree that it may not be necessary to confirm whether the catheter is in the vein
when using a needle with catheter technique.
Consultants and ASA members strongly agree that after the guide wire has been crossed, if it is uncertain whether the catheter or guide wire remains in the vein, it is necessary to confirm the recommendation that the guide wire stay in the vein, and then continue to be placed in a dilator or large-bore catheter
as appropriate 。 Consultants and ASA members strongly agree with the following recommendations: (1) confirm the position of the catheter in the venous system as soon as possible after final catheter insertion and prior to use, (2) confirm the final position of the catheter tip as soon as possible according to the clinical situation, (3) for central venous catheters placed in the operating room, at the latest early postoperative screening to confirm the position of the catheter tip, (4) at the end of the catheterization, by confirming the wire removed from the operating area, to verify that the catheter is not left in the vascular system, (5) If no complete guide wire is found in the operation area, chest x-ray is performed to determine whether the guide wire remains in the patient's vascular system
.

Advice for the prevention of mechanical trauma or damage

Catheter placement position selection

Determine the choice of catheter insertion position based on clinical needs and practitioners' judgment, experience and skills; Whenever possible, select the upper body placement site to minimize the risk of
thrombotic complications associated with the femoral site.

Positioning of the patient during needle entry and catheterization

Where clinical indications are anastomoured and feasible, patients are placed in the Trendelenburg position and central venous access
is opened in the neck or chest.

Needle advance, guide wire intervention, and catheter placement

Selection of catheter size (i.
e.
outside diameter) and type based on clinical circumstances and the operator's skills/experience; Selection of the smallest size catheter suitable for the clinical situation; For subclavian access, choose the thin tube injection needle (i.
e.
, Seldinger) technique versus the needle belt catheter (i.
e.
, modified Seldinger) technique; For jugular venous or femoral approaches, depending on the clinical situation and the skill / experience of the operator, choose the technique of thin tube injection needle or needle with catheter; For entering a vein before piercing a dilator or large-bore catheter, the decision to use the thin tube injection needle technique or needle belt catheter technique depends at least in part on the method used to confirm that the guide wire is in the vein (Figure 1).

The number of puncture attempts should be based on clinical judgment

The decision to place two catheters in one vein should be tailored to the situation
.

Guidance on needle placement, guide wire, and catheter

When selecting the internal jugular vein for intubation, use real-time ultrasound guidance for vascular localization and venipuncture (see Figure 1)##; Where feasible, real-time ultrasound can be used when selecting the subclavian or femoral vein; When choosing an intubation of an internal jugular vein, static ultrasound imaging is used to identify anatomical structures before preparation and coverage to determine vascular localization and patency ; Static ultrasound
can also be used when the subclavian or femoral vein is selected.

Verify the placement of needles, guides, and catheters

After inserting a catheter into the needle or thin tube injection needle, confirm the intravenous access ***†††; Do not rely on the color of the blood or the absence of pulsating blood flow to confirm whether a catheter or thin catheter injection needle is in the vein; When using the thin tube injection needle technique, after threading the guide wire confirms that the wire stays inside the vein; When using needle with catheter technique, it may not be necessary to confirm whether the guide wire is located in the vein (1) when the catheter easily enters the vein, pressure measurement or pressure waveform measurement can clearly confirm the venous position of the catheter, (2) when the guide wire successfully passes through the catheter and enters the vein; If it is uncertain whether the catheter or guide wire is located in the vein, confirm whether the guide wire is located in the vein after the guide wire is penetrated; The dilator or large-diameter catheter can then be inserted ‡‡‡; Confirm the position of the catheter in the venous system as soon as possible after final intubation and before use§§§ in clinically appropriate cases; Confirm the final position ∥∥∥ of the catheter tip as soon as clinically appropriate; For central venous catheters placed in the operating room, chest x-rays are performed at the latest early postoperative to confirm the position of the catheter tip; At the end of the operation, it is confirmed that the steel wire is not retained in the vascular system by confirming whether there is a wire removed in the surgical area; If a complete guide wire is not found in the surgical field, a chest x-ray is performed to determine if the guide wire is retained in the patient's vascular system
.

Note: ∥∥ If venous confirmation is performed using manometry, needle with catheter technique can provide more stable venous access
.

##
.

For newborns, infants, and children, venous placement
can be confirmed after threading the guide wire.

Methods ††† confirm that a catheter or thin catheter needle is located within a vein include, but are not limited to, ultrasound, manometry, or pressure waveform analysis measurements
.

‡‡‡Methods of confirming the presence of a guide wire in a vein include, but are not limited to, ultrasound (recognition of intravenous conduction wires) or transesophageal echocardiography (identification of superior vena cava or right atrial conduction wire), continuous ECG (identification of stenosis complex ectopicals), or fluoroscopy
.

Methods used to confirm that the catheter is still in the venous system after intubation and before use include manometry, pressure waveform measurement, or ultrasonography
.

Treatment of arterial injury caused by indwelling central venous catheter

Findings of the literature study: Case reports indicate that adult patients with arteries punctured by a large-bore catheter/vasodilator during the attempted central venous catheter insertion and immediate removal of the catheter present serious complications (e.
g.
, cerebral infarction, arteriovenous fistula, hemothorax), while complications are rarely reported
in adult patients who remain in place for surgery and repair of the catheter.

Investigations have shown: Specialists and ASA members strongly agree that when a dilator or large-diameter catheter is accidentally inserted into an arterial vessel, leave the dilator or catheter in place and immediately consult a general surgeon, vascular surgeon, or interventional radiologist about surgical or non-surgical removal of
the catheter.
Specialists and ASA members strongly agree that newborns, infants, and children should be consulted on a case-by-case basis to decide whether to leave the catheter in place or remove the catheter
non-surgically.
Specialists and ASA members strongly agree with the recommendation that after assessing the injury and implementing the treatment plan, consult with the surgeon on the relative risks and benefits of elective versus delayed surgery in order to observe the patient for a period of time
.

Treatment of arterial injury caused by an indwelling central venous catheter is recommended

In adults, when an arterial vessel is accidentally inserted using a dilator or large-bore catheter, leave the dilator or catheter in place and consult a general surgeon, vascular surgeon, or interventional radiologist immediately for surgical or non-surgical catheter removal issues
.

For newborns, infants, and children, consult on a case-by-case basis to decide whether to leave the catheter in place or remove the catheter
non-surgically.

After assessing the injury and implementing the treatment plan, consult with the surgeon on the relative risks and benefits of elective versus delayed surgery in order to observe
the patient for a period of time.

Appendix.
Standard example of a special cart for central venous catheterization for adults

Appendix.
Example of a central venous catheter verification sheet

Central venous catheterization standard operation and safety verification sheet

Date: Start Time: End Time:

Operator: Form-filler:

Catheter type: □ central venous □ pulmonary floating catheter

Catheter Type: Catheter Lot Number:

Number of catheter lumens: □1 □2 □ 3 □4

Intubation site: □ internal jugular vein □ upper extremity□ subclavian vein □ femoral vein

Which side: □ left □ right □ both sides

Urgent: □ Timing □ urgent

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