Last updated January 11, 2022

Central Venous Access

Summary of Recommendations

Resource Preparation

Perform central venous catheterization in an environment that permits use of aseptic techniques
Ensure that a standardized equipment set is available for central venous access
Use a checklist or protocol for placement and maintenance of central venous catheters
Use an assistant during placement of a central venous catheter
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Prevention of Infectious Complications

Intravenous Antibiotic Prophylaxis

Do not routinely administer intravenous antibiotic prophylaxis.
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Aseptic Preparation

In preparation for the placement of central venous catheters, use aseptic techniques (e.g., hand washing) and maximal barrier precautions (e.g., sterile gowns, sterile gloves, caps, masks covering both mouth and nose, full-body patient drapes, and eye protection)
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Selection of Antiseptic Solution

Use a chlorhexidine-containing solution for skin preparation in adults, infants, and children
  • For neonates, determine the use of chlorhexidine-containing solutions for skin preparation based on clinical judgment and institutional protocol
If there is a contraindication to chlorhexidine, povidone–iodine or alcohol may be used
Unless contraindicated, use skin preparation solutions containing alcohol.
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Catheters Containing Antimicrobial Agent

For selected patients, use catheters coated with antibiotics, a combination of chlorhexidine and silver sulfadiazine, or silver-platinum-carbon–impregnated catheters based on risk of infection and anticipated duration of catheter use
  • Do not use catheters containing antimicrobial agents as a substitute for additional infection precautions
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Selection of Catheter Insertion Site

Determine catheter insertion site selection based on clinical need
Select an insertion site that is not contaminated or potentially contaminated (e.g., burned or infected skin, inguinal area, adjacent to tracheostomy or open surgical wound)
In adults, select an upper body insertion site when possible to minimize the risk of infection
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Catheter Fixation

Determine the use of sutures, staples, or tape for catheter fixation on a local or institutional basis
Minimize the number of needle punctures of the skin
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Insertion Site Dressings

Use transparent bioocclusive dressings to protect the site of central venous catheter insertion from infection
Unless contraindicated, dressings containing chlorhexidine may be used in adults, infants, and children
For neonates, determine the use of transparent or sponge dressings containing chlorhexidine based on clinical judgment and institutional protocol
If a chlorhexidine-containing dressing is used, observe the site daily for signs of irritation, allergy or necrosis
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Catheter Maintenance

Determine the duration of catheterization based on clinical need
Assess the clinical need for keeping the catheter in place on a daily basis
Remove catheters promptly when no longer deemed clinically necessary
Inspect the catheter insertion site daily for signs of infection
Change or remove the catheter when catheter insertion site infection is suspected
When a catheter-related infection is suspected, a new insertion site may be used for catheter replacement rather than changing the catheter over a guidewire
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Aseptic Techniques Using an Existing Central Venous Catheter for Injection or Aspiration

Clean catheter access ports with an appropriate antiseptic (e.g., alcohol) before each access when using an existing central venous catheter for injection or aspiration
Cap central venous catheter stopcocks or access ports when not in use
Needleless catheter access ports may be used on a case-by-case basis
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Prevention of Mechanical Trauma or Injury

Catheter Insertion Site Selection

Determine catheter insertion site selection based on clinical need and practitioner judgment, experience, and skill
Select an upper body insertion site when possible to minimize the risk of thrombotic complications relative to the femoral site
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Positioning the Patient for Needle Insertion and Catheter Placement

Perform central venous access in the neck or chest with the patient in the Trendelenburg position when clinically appropriate and feasible.
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Needle Insertion, Wire Placement, and Catheter Placement

Select catheter size (i.e., outside diameter) and type based on the clinical situation and skill/experience of the operator
Select the smallest size catheter appropriate for the clinical situation
For the subclavian approach select a thin-wall needle (i.e., Seldinger) technique versus a catheter-over-the-needle (i.e., modified Seldinger) technique
For the jugular or femoral approach, select a thin-wall needle or catheter-over-the-needle technique based on the clinical situation and the skill/experience of the operator
For accessing the vein before threading a dilator or large-bore catheter, base the decision to use a thin-wall needle technique or a catheter-over-the-needle technique at least in part on the method used to confirm that the wire resides in the vein (fig. 1)****
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
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Guidance of Needle, Wire, and Catheter Placement

Use real-time ultrasound guidance for vessel localization and venipuncture when the internal jugular vein is selected for cannulation. 
  • When feasible, real-time ultrasound may be used when the subclavian or femoral vein is selected.
Use static ultrasound imaging before prepping and draping for prepuncture identification of anatomy to determine vessel localization and patency when the internal jugular vein is selected for cannulation.
  • Static ultrasound may also be used when the subclavian or femoral vein is selected.
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Verification of Needle, Wire, and Catheter Placement

After insertion of a catheter that went over the needle or a thin-wall needle, confirm venous access 
  • Do not rely on blood color or absence of pulsatile flow for confirming that the catheter or thin-wall needle resides in the vein

When using the thin-wall needle technique, confirm venous residence of the wire after the wire is threaded
  • When using the catheter-over-the-needle technique, confirmation that the wire resides in the vein may not be needed (1) when the catheter enters the vein easily and manometry or pressure-waveform measurement provides unambiguous confirmation of venous location of the catheter and (2) when the wire passes through the catheter and enters the vein without difficulty
  • If there is any uncertainty that the catheter or wire resides in the vein, confirm venous residence of the wire after the wire is threaded; insertion of a dilator or large-bore catheter may then proceed 
After final catheterization and before use, confirm residence of the catheter in the venous system as soon as clinically appropriate 

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

Verify that the wire has not been retained in the vascular system at the end of the procedure by confirming the presence of the removed wire in the procedural field
  • If the complete guidewire is not found in the procedural field, order chest radiography to determine whether the guidewire has been retained in the patient’s vascular system

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Management of Arterial Trauma or Injury Arising from Central Venous Catheterization

When unintended cannulation of an arterial vessel with a dilator or large-bore catheter occurs, leave the dilator or catheter in place and immediately consult a general surgeon, a vascular surgeon, or an interventional radiologist regarding surgical or nonsurgical catheter removal for adults
For neonates, infants, and children, determine on a case-by-case basis whether to leave the catheter in place and obtain consultation or to remove the catheter nonsurgically
After the injury has been evaluated and a treatment plan has been executed, confer with the surgeon regarding relative risks and benefits of proceeding with the elective surgery versus deferring surgery to allow for a period of patient observation
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Recommendation Grading

Overview

Title

Central Venous Access

Authoring Organization

Publication Month/Year

January 1, 2020

Document Type

Guideline

External Publication Status

Published

Country of Publication

US

Document Objectives

Provide guidance regarding placement and management of central venous catheters; reduce infectious, mechanical, thrombotic, and other adverse outcomes associated with central venous catheterization; and improve management of arterial trauma or injury arising from central venous catheterization.

Inclusion Criteria

Female, Male, Adolescent, Adult, Child, Infant, Older adult

Health Care Settings

Emergency care, Hospital, Operating and recovery room

Intended Users

Nurse anesthetist, medical assistant

Scope

Counseling, Assessment and screening, Management

Diseases/Conditions (MeSH)

D002404 - Catheterization, D002405 - Catheterization, Central Venous

Keywords

Central Venous, catheter, great vessels