Central Venous Access
Publication Date: January 1, 2020
Last Updated: March 14, 2022
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
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
Unless contraindicated, use skin preparation solutions containing alcohol.
- For neonates, determine the use of chlorhexidine-containing solutions for skin preparation based on clinical judgment and institutional protocol
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
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
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
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
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
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
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
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.
- 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
Confirm the final position of the catheter tip as soon as clinically appropriate
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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 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
Confirm the final position of the catheter tip as soon as clinically appropriate
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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
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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
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
American Society of Anesthesiologists
Publication Month/Year
January 1, 2020
Last Updated Month/Year
September 4, 2024
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, nurse, nurse practitioner, physician, physician assistant
Scope
Counseling, Assessment and screening, Management
Diseases/Conditions (MeSH)
D002404 - Catheterization, D002405 - Catheterization, Central Venous
Keywords
Central Venous, catheter, great vessels
Source Citation
Practice Guidelines for Central Venous Access 2020: An Updated Report by the American Society of Anesthesiologists Task Force on Central Venous Access. Anesthesiology. 2020 Jan;132(1):8-43. doi: 10.1097/ALN.0000000000002864. PMID: 31821240.