Central Venous Catheterization Physician Education Module Self-Study

Central Venous Catheterization Physician Education Module Self-Study Principal Faculty: Michael L. Cheatham, MD, FACS, FCCM Chief Surgical Quality Officer Academic Chair, Department of Surgical Education Orlando Regional Medical Center Professor of Clinical Medicine University of Central Florida College of Medicine, Orlando, Florida Co-Clinical Associate Professor of Surgery, Department of Surgery University of Florida, Gainesville, Florida Clinical Professor, Department of Clinical Sciences Florida State University College of Medicine, Orlando, Florida Physician Participation: Physicians read through the material and complete the post-test at the conclusion of this module with a passing score of 80%. The test is graded in Medical Staff Services and results are sent to CME where credits will be uploaded to CE Broker for Florida licensed physicians. Estimated Time to Complete the Educational Activity: 2.0 Hours Release Date: October 1, 2011 Reviewed & Revised Dates: July 25, 2014 November 7, 2016 Termination Date: September 30, 2018 Accreditation: Orlando Health is accredited by the Accreditation Council for Continuing Medical Education to provide continuing medical education for physicians. Orlando Health designates this enduring material for a maximum of 2.0 AMA PRA Category 1 Credits. Physicians should claim only the credit commensurate with the extent of their participation in the activity. Version 4.0 1 Revised 11/07/2016

CME Disclosures: Faculty Disclosures Cheatham, Michael, MD Planners Disclosures Cheatham, Michael, MD Orlando Health CME Committee Disclosures Boyette, Patricia D., MSHS, BSN, NE-BC Deju, Amberly Carrasco, Carlos, OT/L, MBA Cheatham, Michael L., MD Early, Eve Eason, Ronald, MD Hollingshead, Lisa, RN-BC, BSN, MA Johnson, Tirrell, MD Kaplan, Benjamin, MD Khan, Rumi, MD Li, Shuan, MD Lopez, Kelli Meek, Joan, MD Mengel, Marvin, MD, JD Minor, Janelda, MA, RN Morgan, Elizabeth Pietrack, Vicki, LHRM Robinson, Diane, PhD Rosebrock, Anne Russell, Michael, MD Tokarski-Savona, Penelope, MD Ventura, Valerie, MSN/Ed, RN-BC No Commercial Support was provided for this activity. Version 4.0 2 Revised 11/07/2016

CENTRAL VENOUS CATHETERIZATION PHYSICIAN EDUCATION MODULE PURPOSE Effective January 1, 2010, the Joint Commission requires that all healthcare workers involved in the insertion and use of a central venous catheter (CVC) must receive annual education regarding best practices for CVC insertion and prevention of central-line associated bloodstream infection (CLABSI). Completion of this educational module is required for all clinicians who insert CVCs within the Orlando Health affiliated hospitals. Orlando Health is accredited by the Accreditation Council for Continuing Medical Education to provide continuing medical education for physicians. Orlando Health designates this enduring material for a maximum of 2 AMA PRA Category 1 Credits. Physicians should claim only the credit commensurate with the extent of their participation in the activity. Physicians must complete the post-test at the conclusion of this module and achieve a passing score of at least 80% in order to receive CME credit. CME certificates will be mailed to each physician upon submission of the completed educational module to the Orlando Health Medical Staff Services office. The goals of this educational module are: To educate physicians regarding the current best practices for the prevention of CLABSI. To describe a safe and evidence-based medicine approach to central venous catheter (CVC) insertion including: o Indications and contraindications to CVC insertion o Alternatives to CVC use o Anatomy of the subclavian, internal jugular, and femoral vein insertion sites o Maximal barrier precautions o Proper CVC insertion technique o Common procedural complications and techniques to prevent these harm events o Appropriate CVC maintenance and discontinuation To discuss the electronic documentation of CVC insertion and maintenance at Orlando Health. INTRODUCTION Central venous catheter (CVC) insertion is an essential procedure in the treatment of many hospitalized patients. Over 5 million CVCs are inserted annually in the United States for hemodynamic monitoring or medication administration (1). CVC use is associated with the potential for serious infectious, mechanical, and thrombotic complications that may result in significant patient morbidity and mortality. Educating healthcare providers who insert CVCs to prevent central-line associated bloodstream infection (CLABSI) is essential to improving patient outcomes and reducing healthcare costs (2). CLABSI is defined by simultaneous positive peripheral blood cultures and the presence of an indwelling CVC for at least two calendar days on the day of the positive culture. While the incidence of CLABSI has decreased significantly over the past ten years, it is estimated that over 30,000 cases of CLABSI still occur annually with significant patient morbidity and mortality. This educational module is intended to reduce the incidence of such complications by basing CVC use upon well-documented scientific evidence. This is a requirement of the National Patient Safety Goals (NPSG) as mandated by the Joint Commission (Figure 1) (4). The Centers for Disease Control and Prevention (CDC) has identified catheter-related adverse events as one of its seven health care safety challenges (2). The Institute for Healthcare Improvement (IHI) has identified CLABSI prevention as one of the six interventions to prevent patient harm in its 100,000 Lives Campaign (5). Since 2010, CLABSI Version 4.0 3 Revised 11/07/2016

prevention has been a major quality improvement initiative at Orlando Health. Over the past six years, the incidence of CLABSI at Orlando Health has declined significantly, but continued vigilance and attention to CVC insertion and maintenance practices is still necessary to achieve excellent patient care. Figure 1: National Patient Safety Goal 07.04.01: Implement evidence-based guidelines to prevent central line associated bloodstream infections (CLABSI) As of January 1, 2010 The hospital educates health care workers who are involved in these procedures about healthcareassociated infections, CLABSI, and the importance of prevention. Education occurs upon hire, annually thereafter, and when involvement in these procedures is added to an individual s job responsibilities. Prior to insertion of a CVC, the hospital educates patients and families about CLABSI prevention. The hospital implements policies and practices aimed at reducing the risk of CLABSI. The hospital measures CLABSI rates, monitors compliance with best practices or evidence-based guidelines, and evaluates the effectiveness of prevention efforts. The hospital provides physicians, nurses, and other key individuals with CLABSI rates. Healthcare providers use a catheter checklist and a standardized protocol for CVC insertion. Healthcare providers perform hand hygiene prior to catheter insertion or manipulation. For adult patients, do not insert catheters into the femoral vein unless other sites are unavailable. A standardized supply cart or all-inclusive kit is used for the insertion of CVCs. A standardized protocol for maximum sterile barrier precautions is used during CVC insertion. Chlorhexidine-based antiseptic skin preparation is utilized during CVC insertion in all patients over two months of age, unless contraindicated. A standardized protocol is used to disinfect catheter hubs and injection ports before use. All CVCs are reassessed routinely and nonessential catheters removed. Preventative measures that have been identified as being most effective in reducing the incidence of CLABSI are listed in Figure 2. Measures such as these are commonly referred to as a central line bundle. Figure 2: Preventative Measures for Avoiding CLABSI Reduce bacterial colonization at the catheter skin insertion site Ensure appropriate knowledge and use of care protocols Only qualified personnel should be involved in catheter changing and care Maintain good hand hygiene Use chlorhexidine for skin disinfection and manipulation of the vascular line Preferentially use the subclavian vein for insertion of CVCs maintaining full-barrier precautions Evaluate the clinical need for CVCs daily and remove unnecessary catheters Use biomaterials that inhibit microorganism growth and adhesion Proper and continued education of healthcare providers has been shown to decrease the incidence of CLABSI and other CVC-related complications. Catheters inserted by and/or maintained by inexperienced providers have an increased risk for infection (2). Standardization of the insertion technique and aseptic precautions both decrease the risk for infection. The use of central line bundles, procedure carts and/or CVC kits that contain all necessary insertion supplies and procedural checklists have all been demonstrated to be effective measures for reducing CVC-related complications and providing improved patient care. OPTIONS FOR VASCULAR ACCESS There are many different options for vascular access. These can generally be divided into two types: peripheral and central. The choice of vascular access device should be determined by the expected duration of infusion therapy, the need for centrally-administered medications, and the risk of infectious, thrombotic, and mechanical complications (Figure 3). Intravenous catheters should always be removed as soon as they are no longer necessary to the patient s ongoing care. Version 4.0 4 Revised 11/07/2016

Peripheral intravenous catheters (PIV) are often under-utilized due to the ease of CVC insertion. PIV are good routes of administration for fluids and intravenous medications. As they require replacement every 72 hours, they are not associated with significant rates of catheter-related bacteremia (3). Their use can be complicated by localized phlebitis. They should NOT be used to infuse vasoactive medications (such as dopamine, dobutamine, neosynephrine, norepinephrine, etc ) as extravasation of these agents can lead to tissue necrosis and significant morbidity (Orlando Health policy #5025: Continuous administration of vasoactive medications ). PIV inserted in emergent situations should be considered contaminated and at high risk for septic phlebitis. They should be replaced by a new PIV or a CVC as soon as possible and no later than 24 hours after insertion. PIV should always be considered as an alternative to a CVC in the patient with fever whose CVC is no longer necessary for patient monitoring or resuscitation. Midline catheters are specialized peripheral intravenous catheters that are longer and may remain in place for up to four weeks. They should not be used for medications that require central venous administration as they terminate in the upper arm. They are a good alternative to peripherally inserted central catheters (PICC) as they have a lower risk of infection and thrombotic complications. Peripherally inserted central catheters (PICC) are a popular route for central venous access that are placed by specially trained nurses or technicians. Due to their peripheral insertion, they significantly minimize the risks of hemothorax and pneumothorax associated with CVC placement. They are commonly considered to be both cost-effective and associated with lower morbidity based upon trials of outpatient and neonatal PICC use. Among hospitalized patients, however, they are associated with CLABSI rates that are equivalent to those of CVCs (2.1 infections per 1,000 catheter days [95% CI 1.7-2.5]) and are associated with higher rates of venous thrombosis, phlebitis, and catheter malfunction (6-8). PICCs are good choices for patients requiring total parenteral nutrition or antibiotic therapy where the catheter ports will not be frequently accessed. The choice of PICC vs. CVC should be made based upon the individual patient s needs, the availability of a physician to insert a CVC, and the patient s severity of illness. Figure 3: Indications for Intravenous Access Devices Peripheral intravenous catheter o Infusion therapy duration less than 7 days o Infusion therapies that do not require central line administration Midline catheter o Infusion therapy duration of 1 to 4 weeks o Infusion therapies that do not require central line administration Central lines (subclavian, internal jugular, femoral, PICC, tunneled, port) o Infusion therapy duration of 1 to 4 weeks or longer o Infusion therapies that require central line administration, have a ph less than 5 or greater than 9, or have an osmolarity greater than 600mOsm/L o All peripheral access options have been exhausted o Infusion therapies cannot be administered via other routes Version 4.0 5 Revised 11/07/2016

INDICATIONS / CONTRAINDICATIONS FOR CENTRAL VENOUS CATHETERIZATION CVCs are used to provide secure access to the central circulation for medication administration, fluid resuscitation, and/or total parenteral nutrition. They are required for vasoactive medication administration. They are associated with higher rates of CLABSI than peripheral intravenous catheters. Common indications for CVC insertion include the following: Emergency resuscitation / rapid infusion of fluids Delivery of essential fluids and medications Continuous monitoring of central venous pressure (CVP) Administration of potent vasoactive medications Total parenteral nutrition Transvenous pacing Pulmonary artery catheterization Hemodialysis / hemofiltration Lack of peripheral venous access Relative contraindications to CVC insertion include: Coagulopathy (INR > 2.0, platelets < 50,000) Infection over the target vein Thrombosis of the target vein Radiation therapy over the insertion site Scarring of the insertion site Erythema of the insertion site Ability to administer medications using a peripherally inserted catheter RISKS OF CENTRAL VENOUS CATHETERIZATION The risks of CVC-related complications may generally be divided into three types: infectious, mechanical, and thrombotic. These complications can lead to significant patient morbidity and mortality including infection, pneumothorax, hemothorax, hematoma, thrombosis, arrhythmia, and arterial puncture. Proper insertion technique and compliance with catheter insertion and maintenance protocols have been shown to significantly reduce the incidence of such complications, improve patient outcome, and reduce patient care costs (2,3,9-15). Infectious complications CLABSI is the most serious complication of central venous access and a leading cause of nosocomial infection in the ICU (2). As a foreign body, CVCs typically become colonized from one of four sources (3,9,10). Methods intended to reduce the incidence of infection typically address one of these four areas of contamination (in decreasing order of frequency). 1) Extraluminal migration of skin microorganisms down the catheter insertion tract with colonization of the catheter tip. Coagulase-negative staphylococci are the most common organisms identified in CLABSI followed by Staphylococcus aureus, Candida species, Enterococci, and Gram-negative bacilli (2). The deposition of a host protein sheath around the intravascular portion of the indwelling catheter facilitates adherence of microorganisms to the catheter leading to colonization. 2) Intraluminal catheter colonization following contamination of the catheter hubs by contact with hands or contaminated fluids or devices 3) Hematogenous seeding from a remote source of infection 4) Administration of contaminated infusate The rate of CLABSI varies depending upon the patient population. On average, 5.3 CLABSIs occur per 1,000 catheter days or 3 to 8% of all inserted catheters (2,16). The attributable mortality of CLABSI ranges from 0 to 35% (2,11,16). Important pathogenic determinants of CLABSI include 1) the material from which the catheter is made, 2) the host factors consisting of protein (fibrin and fibronectin) deposits that form a sheath around the catheter, and 3) the intrinsic virulence factors of the infecting organism (3). Efforts to Version 4.0 6 Revised 11/07/2016

reduce the risk of CLABSI should focus on two specific phases - CVC insertion and daily maintenance as these aspects of CVC use are associated with the greatest risk for patient injury. To decrease the risk of CLABSI, CVCs should be evaluated daily and catheters removed when they are no longer needed for patient monitoring or resuscitation. Mechanical complications CVC insertion may also be associated with mechanical complications including, but not limited to, failure to locate or cannulate the vein, puncture of adjacent anatomic structures, catheter misplacement, pneumothorax, hemothorax, arterial injury, mediastinal hematoma, and adjacent nerve injury (1). Mechanical complications are reported to occur in 5 to 19% of catheter insertions (11). Thrombotic complications Patients who require CVC are at high risk for catheter-related thrombosis as a result of their critical illness. Such thromboses can lead to fever, extremity edema, pulmonary embolus, and loss of the vein for subsequent CVC insertion. Thrombotic complications occur in 2 to 26% of patients (11). ECONOMIC IMPACT OF CLABSI The associated cost of a single CLABSI is estimated at $25,000 to $56,000 resulting in an annual economic impact of $300 million to $2.3 billion per year (2). Each CLABSI adds one extra week in the ICU and two to three additional weeks in the hospital for each infected patient. CENTRAL VENOUS CATHETER INSERTION The following discussion details an evidence-based medicine approach to the insertion and maintenance of CVCs. Catheter Choice The choice of catheter should be based upon the current needs of the patient. CVCs may contain anywhere from a single lumen up to five lumens and vary in the diameter and flow rate of each lumen. In general, the greater the number of lumens, the more frequently the catheter will be accessed and manipulated theoretically increasing the risk of catheter-related infection. As a general rule, choose the catheter with the fewest lumens necessary. For resuscitation or hemodialysis, large-bore catheters are preferable as there is less resistance to flow allowing for faster infusion rates. Certain medications (such as total parenteral nutrition or propofol) must be administered through a dedicated lumen which may increase the number of lumens required. In general, a 7-French triple-lumen catheter of 16 to 20 cm length is appropriate for the majority of adult patients. Catheter Material The material from which a CVC is manufactured plays an important role in the prevention of catheter-related infection. In recent years, polyvinyl chloride and polyethylene catheters have been replaced with polyurethane catheters which are associated with fewer infectious complications. Additionally, catheters are now commonly coated with antimicrobial or antiseptic agents intended to decrease microorganism adhesion and biofilm production, thus further decreasing the risk of catheter-related infection. These antimicrobial / antiseptic coated catheters have been demonstrated to decrease hospital costs (as a result of decreased CLABSI rates) offsetting the increased cost of the catheter (2). The majority of commercially available CVCs are now coated with either chlorhexidine/silver sulfadiazine or minocycline/rifampin. Compared to traditional catheters, these coated catheters significantly decrease both the risk of catheter colonization (relative risk, RR: 0.59 [95% CI: 0.50-0.71]) and bloodstream infection (RR: 0.66 [95% CI: 0.47-0.93]) (17). There is no evidence to suggest that antimicrobial coated catheters result in the development of multi-drug resistant bacteria. Version 4.0 7 Revised 11/07/2016

Insertion Technique Prior to inserting a CVC, the patient and/or family should be informed of the proposed procedure as well as the potential risks and benefits of central venous catheterization. Appropriate informed consent should be obtained. The patient should be examined with close attention to the proposed insertion site(s) to identify any potential anatomic difficulties or contraindications. Prevention of CLABSI is a team-effort. Clinicians should defer elective CVC insertions until a nurse is available to assist in the catheter s insertion. If any member of the team notes a deviation in technique (such as a contaminated sterile field, etc ), the clinician performing the procedure should be immediately notified and the deviation in technique corrected before the procedure continues further. At any point in the CVC insertion procedure, all members of the insertion team (physician, nurse, respiratory therapist, etc ) are empowered to halt the procedure if there has been a break in sterile technique or the patient is at risk for injury. All invasive procedures should be performed in a sterile manner with strict attention to aseptic technique. General principles for invasive catheter insertion include the following: Maximal barrier precautions (cap, mask, sterile gown, sterile gloves for all procedures) Good hand hygiene Appropriate patient positioning Proper skin antisepsis using 2% chlorhexidine gluconate Wide draping of the sterile field Appropriate patient sedation and analgesia Careful choice of catheter insertion site Antimicrobial-coated central venous catheters Careful insertion technique Appropriate catheter dressings and catheter/site care Removal of unnecessary or infected CVCs Maximal Barrier Precautions Maximal sterile barrier precautions during CVC insertion including the use of a surgical cap, surgical mask, protective eyewear, sterile gown, sterile gloves, and a large sterile drape that covers the patient s entire body have been demonstrated to significantly reduce the incidence of CLABSI when compared to insertion using sterile gloves and a small drape alone (9,11,16). This should be considered the standard of care for any CVC insertion. Any deviation from these precautions or break in sterile technique, outside of an emergent life-threatening situation, should result in an immediate cessation of the procedure until the deviation can be corrected (2,16). Inadequate draping of patient Correct draping of patient (Maximal Barrier Precautions) Version 4.0 8 Revised 11/07/2016

Proper Hand Hygiene Hand washing is an extremely effective way to prevent nosocomial infections. Good hand hygiene, combined with proper aseptic technique during catheter insertion and manipulation, is an effective method for reducing infectious complications (2). Even if healthcare providers wear gloves, studies have consistently shown that hand washing immediately prior to the handling of a CVC reduces the incidence of infection. Good hand hygiene can be achieved using either antibacterial soap and water or a waterless, alcohol-based hand rub. This should be performed both before insertion and whenever the CVC is accessed or redressed. Appropriate Patient Positioning Proper patient positioning is essential to successful CVC insertion and must not be overlooked. The patient should be placed in the Trendelenburg position during CVC insertion in order to reduce the risk of air embolism and increase the diameter of the subclavian and internal jugular veins. Placement of a towel roll between the patient s shoulder blades can assist in successfully accessing the subclavian vein by allowing the patient s shoulders to fall posteriorly. If the patient is conscious, explain that his/her face will be covered, but that breathing will not be obstructed, and that they can signal for attention by talking or raising their hand. Patient in Trendelenburg position Proper Skin Antisepsis The density of microorganisms at the catheter insertion site is a major risk factor for catheter-related infection. Skin antisepsis is therefore one of the most important preventive measures in reducing the risk of CLABSI. Povidone-iodine (Betadine) has traditionally been used as the skin antiseptic for invasive procedures. The use of a 2% chlorhexidine gluconate solution rather than povidone-iodine, however, has been demonstrated to reduce the risk of CLABSI by approximately 50% (RR: 0.51 [95% CI: 0.27-0.97]) (2,18). Current evidence supports the use of 2% chlorhexidine gluconate for skin preparation prior to CVC insertion in adults and children; the safety of such solutions in neonates remains unclear. Povidone-iodine should be utilized only in patients with an allergy to chlorhexidine. Regardless of the antiseptic solution selected, the skin should be prepped for a radius of 10 centimeters around the proposed insertion site using a circular motion. The total prep time should last at least 60 seconds and the skin prep solution should always be allowed to dry thoroughly before any procedure is commenced. Allow povidone-iodine to remain on the skin for at least 2 minutes or longer for its antibacterial properties to take effect. The antibacterial properties of chlorhexidine work on contact and catheter insertion may begin as soon as the chlorhexidine is dry. Prophylactic antibiotics The use of prophylactic antibiotics has not been demonstrated to reduce the risk of CLABSI and their use should be avoided due to concern that such therapy will lead to emergence of antibiotic-resistant organisms as well as nosocomial infections such as Clostridium difficile colitis. Prospective, randomized trials have failed to demonstrate a benefit to applying antibiotic or antiseptic ointment (e.g., bacitracin, mupirocin, neomycin, polymixin) to CVC insertion sites with the exception of hemodialysis catheters (10,16). Such practices increase the rate of catheter colonization by Candida species (as they do not possess fungicidal activity), promote the emergence of antibiotic-resistant bacteria, can damage the integrity of intravascular catheters, and do not lower the rate of CLABSI (2,9,11,16,19). Systemic antibiotic prophylaxis should not be used during catheter insertion or maintenance with the goal of preventing CLABSI. Version 4.0 9 Revised 11/07/2016

Appropriate patient sedation and analgesia CVC insertion can be anxiety provoking for some awake patients. Verbal reassurance and explanation of the CVC insertion process is required. Some patients may require administration of small doses of an anxiolytic (such as midazolam or lorazepam). Proper analgesia using appropriate insertion of local anesthetic is also essential. This can decrease the risk of iatrogenic mechanical complications (such as pneumothorax and hemothorax) through decreased patient movement, decrease the patient s level of discomfort, and improve the entire process for the patient. Choice of catheter insertion site Due to the relatively straight pathway to the superior vena cava, the left subclavian and right internal jugular vein sites are most commonly used as initial insertion sites. The left internal jugular vein site is the least desirable of the possible sites due to 1) the angle at which the left internal jugular joins the subclavian vein which can make catheter passage difficult, and 2) an increased risk of both pneumothorax and thoracic duct injury. As direct compression of the subclavian artery and vein is not possible, the internal jugular and femoral vein sites are preferable in patients at risk of bleeding. Femoral vein catheterization should not be performed in the presence of penetrating abdominal trauma or known inferior vena cava disruption. Subclavian catheterization is more likely than internal jugular catheterization to be complicated by pneumothorax and hemothorax, whereas internal jugular catheterization is more likely to be associated with arterial puncture. Internal jugular vein access may be preferred in patients with or at risk for renal failure in order to decrease the incidence of subclavian thrombosis, which could complicate subsequent upper extremity dialysis access creation. In addition to a higher CLABSI rate, femoral catheterization is also associated with a high rate of hematoma and arterial puncture as well as a 25% incidence of deep venous thrombosis (2,11,16). As a result, the subclavian vein is the preferred site of insertion as it has been shown to be associated with both a significantly lower infection rate and a lower risk of catheterrelated thrombosis compared to the internal jugular and especially femoral veins (2,9,11,16,21). When absolutely necessary, femoral CVC insertions should be removed and changed to either a subclavian or internal jugular vein site as soon as possible (20). In contrast to adults, pediatric CVC studies have demonstrated that femoral vein catheters have a low incidence of mechanical complications and an equivalent infection rate to that of non-femoral catheters (3). Adult CLABSI Rates by Insertion Site (20) Catheter Insertion Site CLABSI Rate Subclavian vein 4.0 per 1,000 catheter days Internal Jugular vein 8.6 per 1,000 catheter days Femoral vein 15.3 per 1,000 catheter days Antimicrobial-Coated Central Venous Catheters Antimicrobial-coated CVC are now commonplace and have been found to both reduce the risk of CLABSI and its cost (11). Maki et al. performed a prospective, randomized, controlled trial of such catheters demonstrating that their use significantly reduces the incidence of CLABSI from 7.6 to 1.6 infections per 1,000 catheter days (relative risk 0.21; p=0.03) (10). Subsequent systematic literature reviews have demonstrated that antimicrobial-impregnated catheters not only reduce the incidence of CLABSI, but also decrease complications and are cost-effective (2,22). Minocycline-rifampin impregnated catheters have been demonstrated to be equivalent to chlorhexidine-silver sulfadiazine impregnated catheters (11). Version 4.0 10 Revised 11/07/2016

CVC INSERTION TECHNIQUE The following discussion outlines the anatomy and appropriate steps for inserting a subclavian, internal jugular, or femoral vein CVC. Inserting a CVC utilizing such a standardized approach has been demonstrated to significantly reduce the risk of CVC-related complications. A brief video outlining the appropriate steps of CVC insertion can be accessed under the Instructional Videos at www.surgicalcriticalcare.net. Supplies needed at bedside Mask Cap Eye protection Sterile gown Sterile gloves (2 pairs) Central venous catheter insertion kit containing a large sterile full-body drape 2% chlorhexidine gluconate skin prep Sterile saline flush syringes Procedure 1. Notify the patient s nurse of the CVC procedure so that they may be present and assist. 2. Explain the procedure to the patient including the potential risks and benefits, obtain informed consent, and answer any questions the patient may have. 3. Confirm the patient is not allergic to either chlorhexidine gluconate or lidocaine. 4. Place the patient on a bedside EKG monitor or pulse oximeter OR communicate with patient throughout procedure to ensure systemic perfusion and absence of cardiac arrhythmias. 5. Together with the patient s nurse, complete the Pre-insertion Checklist / Time-Out to confirm the right patient, right procedure, right site, and right equipment are present. 6. For subclavian or internal jugular vein insertions, place the patient in the Trendelenburg position with a towel roll between the patient s shoulder blades. For femoral vein insertions, place the patient supine with the legs slightly abducted. 7. Don the mask, cap, eye protection, and sterile gloves. 8. Widely prep the proposed catheter insertion site and surrounding skin (approximately 10 inches in diameter) with the chlorhexidine solution, allowing it to dry completely. 9. Don the sterile gown and a new pair of sterile gloves. 10. Widely drape the entire patient applying the drape so that the hole in the plastic portion of the drape overlies the intended insertion site. 11. For subclavian or femoral vein insertions, the operator should be on the patient s side. For internal jugular vein insertions, the operator should be at the patient s head. 12. Infiltrate the skin of the proposed insertion site with 1% lidocaine. 13. Accessing the vein: For the subclavian vein, confirm the relative position of the sternal notch and the middle third of the clavicle. Insert the needle 1 centimeter below and 1 centimeter lateral to the middle third of the clavicle. The needle tip should be aimed at the sternal notch. The barrel of the syringe should always be maintained parallel to the floor to avoid injury to the lung. Pulling the patient s ipsilateral arm down may facilitate localizing the vein. Advance the needle with continuous suction applied to the syringe until blood flows freely into the syringe. The vein is usually accessed after advancing the needle 3 to 5 centimeters depending upon the patient s size and anatomy. For the internal jugular vein, the patient s head should be turned away from the proposed insertion site. Identify the triangle formed by the sternal and clavicular heads of the sternocleidomastoid muscle and the clavicle. Determine the location of the carotid pulse; the path of the internal jugular vein runs just lateral to the carotid artery. The needle should enter the skin at the apex of the triangle, just lateral to the carotid pulse, aiming for the ipsilateral nipple with the barrel of the syringe maintained at a 45 degree angle. Advance the needle with continuous suction applied to the syringe until blood flows freely into the syringe. The vein is usually accessed at a depth of 1 to 2 centimeters. Some physicians advocate using a 21-gauge Version 4.0 11 Revised 11/07/2016

finder needle to locate the internal jugular vein prior to using the 16-gauge needle. This decreases the risk of injuring the carotid artery with the larger needle while attempting to locate the vein. For the femoral vein, the femoral artery pulse should be identified just below the inguinal ligament and midway between the anterior superior iliac spine and the pubic tubercle. Insert the needle medial to the palpable femoral pulse with the barrel of the syringe angled cephalad and maintained at a 45 degree angle to the skin. Advance the needle with continuous suction applied to the syringe until blood flows freely into the syringe. The vein is usually accessed at a depth of 2 to 4 centimeters. 14. Once the vein has been localized, stabilize the needle and detach the syringe. Immediately insert the guidewire into the needle and pass it into the vein. Stop if resistance is felt. The guidewire should thread easily. If not, gently remove the wire, reattach a syringe, and reconfirm free aspiration of blood before reattempting guidewire passage. DO NOT pull the guidewire back through the needle if resistance is felt as this may shear the guidewire tip, embolizing it into the central circulation. 15. With the guidewire passing easily through the needle, observe the patient s monitor closely for arrhythmias OR communicate with the patient to ensure that they remain conscious. If arrhythmias occur, withdraw the guidewire until they cease. 16. Create a stab wound in the skin at the guidewire insertion site using a scalpel. 17. Gently pass the dilator over the wire and into the skin. DO NOT hub the dilator. Remove the dilator. 18. Pass the CVC over the guidewire maintaining control of the wire at all times. Insert the catheter to an appropriate position based upon the patient s size. 19. Apply the clamp fastener over the flexible catheter clamp. Suture the clamp fastener and flexible catheter wings to the skin after infiltration with local anesthetic. 20. Aspirate blood from all ports to confirm appropriate positioning. Flush ports with sterile saline. 21. Suture the catheter and apply a chlorhexidine-impregnated patch (Biopatch ) around the catheter. 22. Clean the site and apply a sterile, occlusive dressing. 23. All sharps should be properly disposed of in an appropriate sharps container. This is the performing clinician s responsibility. 24. For subclavian and internal jugular insertions, obtain a chest radiograph to document proper catheter tip placement and to ensure that there is no pneumothorax or hemothorax. The tip of the catheter must be in the distal superior vena cava at the junction of the right atrium. The catheter should be parallel to the vena cava wall. 25. For femoral vein insertions, the catheter should be positioned in the external iliac vein. 26. Document the CVC insertion in the medical record including the time and date of insertion using the CVC Insertion procedure note template. Ultrasound-guided CVC insertion The use of bedside ultrasound during CVC insertion has been demonstrated to reduce the risk of procedural complications. Ultrasound can help identify aberrations in anatomy, facilitate rapid CVC insertion, and decrease the risk of arterial puncture (2). All physicians who insert CVCs should become familiar with the use of bedside ultrasound. When a difficult catheterization is anticipated, the procedure should be performed or supervised by an experienced physician and ultrasound guidance should be utilized (20,23,24). During internal jugular CVC placement, the use of ultrasound guidance reduces the number of mechanical complications, the number of catheter placement failures, and the time required for insertion. Randolph et al. performed a meta-analysis of 8 clinical studies evaluating the use of bedside ultrasound in the placement of CVCs (24). This technology significantly reduced the incidence of mechanical complications compared to traditional insertion techniques (relative risk 0.22; 95% CI: 0.10-0.45). A randomized study of 900 ICU patients demonstrated a significant reduction in CLABSI among patients in whom ultrasound-guidance was utilized (10.4% vs. 16.0%; p< 0.01) (24). CVC insertion-related complications The ability to recognize the risk factors for difficult catheterization is essential. A history of failed catheterization attempts, a complex body habitus (as noted above), the need for catheterization at sites of prior surgery, skeletal deformity, or scarring all suggest that catheterization may be difficult. Insertion by a Version 4.0 12 Revised 11/07/2016

physician who has performed more than 50 CVC procedures is half as likely to result in a mechanical complication compared to a physician who has performed fewer than 50 insertions (11). Mansfield et al. studied the success and complications associated with subclavian vein catheterization in 821 patients (1). Multivariate analysis identified that prior major surgery in the region, a body-mass index (weight in kilograms divided by the square of the height in meters) greater than 30 or less than 20, previous catheterization, and multiple attempts at vein localization were significantly associated with both complications and failure. If only a single needle pass was required, the complication rate was 4%, as compared with 11% for two passes, and 24% for three or more passes. Similarly, the failure rate was 1.6% for one pass, 10% for two passes, and 43% for three or more passes. The strongest predictor of complication was a failed catheterization attempt. If access to the vein has not been successfully achieved after three passes of the needle, a new physician should attempt to insert the CVC. The authors recommended that CVCs in high-risk patients (as defined above) should be attempted by the most experienced physician available. Kilbourne et al. studied the videotaped CVC insertions of 86 patients (25). The overall needle insertion failure rate (defined as insertion of a needle into the skin that did not result in successful passage of a guidewire into the vein) was 78%. The mean number of failed attempts per successful CVC insertion was 3.2 (5.5 on the right and 2.1 on the left; p=0.016) while that for failed CVC insertion was 8.0 attempts. Based upon the significant increase in difficulty with right subclavian CVC insertion for right-handed operators, the patient s left side is recommended if the clinical situation permits. The authors identified the following common errors in CVC insertion. Six Most Common Technical Errors in Subclavian Vein CVC Insertion (25) Technical Error Rate Explanation Failure to insert the needle at a recommended distance of about 1 cm Improper insertion inferior and lateral to the middle or medial third of the clavicle. Close position relative to 32% proximity to the clavicle creates a steep angle for cannulating the vein the clavicle beneath the clavicle. Insertion of the needle through the clavicular periosteum Taking too shallow of a trajectory of the needle Improper or inadequate anatomic landmark identification Aiming the needle too cephalad Failure to keep the needle in place for wire passage 22% 16% 15% 8% 8% In an effort to walk the clavicle down to locate the vein posteriorly, using significant force or aggressively pushing the needle can drive it through, instead of beneath, the periosteum. In addition to increasing the rate of unsuccessful venipunctures, this complicates subsequent dilation and passage of the catheter over the guidewire. After the needle is passed posterior to the clavicle, the angle is dropped significantly, causing the needle to only nick the vein anteriorly. Failure to palpate two bony landmarks, the sternal notch and the middle to medial third of the clavicle, before and during each attempt. It is relatively easy to lose track of one s line of insertion amid needle manipulation and sterile draping. In order to avoid the pleural apex (and pneumothorax), the needle trajectory is superior to the sternal notch. This places both the subclavian vein and artery at risk for injury. Backward retraction of the needle with syringe removal can prematurely pull the needle out of the vein and cause inability to pas the wire. Operators who do not have the guidewire on the field or must turn their body to retrieve it from the catheter tray are most prone to this mistake. Twenty centimeter long catheters are suitable for the vast majority of adult patients. In general, CVCs should be inserted to 15 centimeters at the level of the skin in the right subclavian and internal jugular vein positions and 18 centimeters at the level of the skin in the left subclavian and internal jugular vein positions (these recommendations should be adjusted based upon patient size and anatomy). CVCs should rarely be inserted to their full length except in large or obese patients. Catheters should be secured to the skin using suture or staples as well as the locking device provided with each catheter. A loosely-anchored CVC that slides back and forth at the skin insertion site increases the risk for contamination of the insertion tract. Version 4.0 13 Revised 11/07/2016

Since skin flora are the most common infecting organisms in CLABSIs, proper CVC anchoring is strongly recommended. Common complications Arterial Puncture Arterial puncture during CVC insertion is most commonly identified by the presence of pulsatile, bright red bleeding from the needle when attempting to insert the guidewire. If such bleeding is present, remove the needle and apply direct pressure to the insertion site for ten minutes or until there is no further bleeding. If there is a question as to whether or not the bleeding is arterial, the needle may be connected to a pressure transducer and the blood pressure within the vessel measured or a short piece of intravenous tubing may be connected to the needle as a manometer. Pneumothorax Air may occasionally be aspirated into the syringe during CVC insertion. Most commonly, this occurs when the needle is not firmly attached to the syringe. If properly attached, aspirated air may be due to violation of the pleural space and development of a pneumothorax, especially if the patient is complaining of difficulty breathing or the patient s arterial oxygen saturations are dropping. Immediately remove the needle and obtain a STAT chest radiograph. If the patient s respiratory distress worsens, a chest tube may need to be inserted before the chest radiograph is available. A chest radiograph should always be inspected after each new subclavian or internal jugular vein CVC insertion to confirm the absence of a pneumothorax or hemothorax. If an attempt to insert a subclavian or internal jugular vein CVC is unsuccessful, a chest radiograph should be obtained before an attempt on the contralateral vein(s) is attempted to confirm the absence of a pneumothorax. While a small unilateral pneumothorax is generally tolerated by a patient, bilateral pneumothoraces are not and can lead to rapid respiratory failure. Hemothorax Hemothorax is rare, but can occur following arterial puncture or venous laceration. Small hemothoraces are generally tolerated well, but larger hemothoraces or those in patients on anticoagulation (aspirin, warfarin, clopidogrel, etc ) will usually require chest tube insertion. Cardiac Arrhythmias Arrhythmias are the most common complication of CVC insertion, but are usually transient and inconsequential. If arrhythmias are detected on the patient s bedside monitor during CVC insertion, the tip of the guidewire or catheter may be in the patient s right atrium. The guidewire or catheter should immediately be withdrawn several centimeters until the arrhythmias cease. These are most commonly premature atrial or ventricular contractions, but ventricular tachycardia may also occur. Choosing the proper length of CVC based upon the patient s size and careful insertion of the guidewire both help to minimize this complication. Air embolism If air embolism is suspected during the procedure, the patient should be immediately placed in steep Trendelenburg position with a left lateral decubitus tilt to prevent movement of air into the right ventricular outflow tract. Air embolism may be detected by auscultation of a classic, millwheel cardiac murmur. The patient should be placed on a FiO2 of 1.0, and, if the catheter is in the heart, aspiration of air should be attempted. Version 4.0 14 Revised 11/07/2016

Guidewire shearing The tip of the insertion needle is very sharp and can cut the guidewire if it is forcefully withdrawn from the needle. If any resistance to removal of the guidewire is felt as the guidewire is withdrawn through the needle, the insertion needle and guidewire should BOTH be withdrawn as a unit. The needle may then be reinserted into the vein and guidewire passage reattempted. Forceful withdrawal of the guidewire through the needle can result in shearing off the distal portion of the guidewire with subsequent embolization into the central circulation. Inability to advance the guidewire If the guidewire will not thread easily through the insertion needle, the needle may have become inadvertently dislodged from the vein. Carefully remove the guidewire (see Guidewire shearing above), reconnect a syringe, and ensure that free flow of blood through the needle is possible. If not, adjust the position of the needle and reaspirate until free flow of blood is present again and reattempt passage of the guidewire. If you are still unable to reestablish blood flow, remove the insertion needle, flush it with saline, and reaccess the vein. If free flow of blood is present, but the guidewire will still not pass, have an assistant pull the patient s ipsilateral arm down towards the feet. Reattempt threading the guidewire. If guidewire passage is still not successful, the vein may be thrombosed proximally (especially if CVCs have been placed in that vein previously) and a new insertion site should be chosen. CATHETER MAINTENANCE Appropriate catheter site dressings and care play an important role in the prevention of CLABSI. Proper care begins at the time of catheter insertion. Catheter site dressings and catheter/site care The existing data suggests that transparent semi-permeable polyurethane dressings (i.e., Tegaderm, OpSite, etc ) are equivalent to sterile gauze in their ability to prevent CLABSI (2). Further, such dressings assist in securing the catheter, permit continuous visual inspection of the catheter insertion site, permit patients to bathe and shower without saturating the dressing, require less frequent changes than standard gauze dressings, and save nursing time (2). If blood is oozing from the insertion site, however, sterile gauze dressings changed frequently are preferable to avoid accumulation of blood that might serve to promote insertion site colonization (9). Placement of a chlorhexidineimpregnated sponge can significantly reduce the risk of CLABSI from 1.3 Proper application of Biopatch to 0.4 infections per 1,000 catheter days (hazard ratio 0.24 [95% CI 0.09-0.65]) (25). Such dressings must be placed properly with the blue side facing up away from the patient ( blue towards the sky ). Excessive manipulation of catheters increases the risk for CLABSI (likely because of the greater risk for a breach in aseptic technique each time the catheter is accessed). As a result, whenever possible, the number of times a CVC is accessed should be minimized in order to decrease this risk. Prior to accessing any line, hands should be washed, gloves should be worn, and the hub should be sterilized with an alcohol swab. CVC replacement and removal of clinically unnecessary or infected CVCs The continued need for a CVC should be assessed daily and removal considered when the catheter is no longer essential for the patient s ongoing resuscitation and care. The use of the enteral or oral route to deliver medications and nutritional support should be encouraged whenever possible to allow removal of unnecessary CVCs. Any CVC inserted emergently should be considered contaminated, as it is the exception rather than the rule that aseptic insertion technique is used in such emergency situations. Such catheters should be changed to a new site as soon as hemodynamic and respiratory stability permits, Version 4.0 15 Revised 11/07/2016

but certainly within 24 hours of initial placement. Properly inserted and maintained CVCs are virtually never a source for sepsis in the first 72 hours after placement. After 72 hours, the risk of CLABSI increases. CVC catheters may remain in place indefinitely provided that they continue to provide useful physiologic information, they continue to function (without technical problems), and there is no evidence of suspected CLABSI. Prophylactic, routine CVC replacement as a strategy to prevent infection should not be performed (3). This has been demonstrated to increase the risk of catheter-related infection and is associated with a higher rate of mechanical complications (27). Absolute indications for CVC change or removal: A positive blood culture drawn greater than 48 hours after the catheter was inserted A grossly infected insertion site A non-functioning catheter (i.e., occluded ports) Clinical suspicion of line-related sepsis (fever spike >38.3º C or >1.5º C above baseline) A positive intracutaneous segment on a previously guidewire-exchanged CVC Relative indications for CVC change or removal: Clinical suspicion of secondary seeding of the line from a primary septic source (fever spike >38.3º C or >1.5º C above baseline in a patient with a known septic source) Lack of a sterile port for parenteral nutrition Requirement of an introducer for pulmonary artery catheter insertion Guidewire catheter exchange should generally be avoided and reserved for malfunctioning catheters only. It should not be performed if there is any suspicion that the catheter or site are infected. Guidewire exchange is associated with a decreased risk of mechanical complications (e.g., pneumothorax, hemothorax, etc ) (relative risk 0.48), but an increased risk of CLABSI (relative risk 1.26-1.52) compared to new site placement (27). Whenever a guidewire catheter exchange is performed, the intracutaneous segment should be sent for semiquantitative culture (never the tip ) (28). The intracutaneous segment represents the 3 centimeter segment of the previous catheter that was immediately below the skin. Since extraluminal colonization represents the most common route of CLABSI, if the segment has no significant growth (i.e., < 15 colony forming units (CFU)), the catheter site is not colonized and the new catheter may be left in place. If the culture is positive (>15 CFU), the catheter should be removed at once and a new insertion site used. If a CVC is simply being discontinued due to lack of clinical need, the catheter does not need to be cultured. If CVC colonization is suspected, three blood cultures should be drawn to evaluate the possibility of bacteremia with one of the three cultures drawn through the CVC and the other two cultures peripherally. A negative blood culture drawn from a CVC indicates that the presence of a CLABSI is unlikely. PREVENTING CLABSI THROUGH EDUCATION Warren et al. performed an observational evaluation of lectures, posting of CLABSI rates, and use of a selfstudy module on the prevention of CLABSI in a community hospital (13). The rate of CLABSI decreased from 4.9 per 1,000 catheter days to 2.1 per 1,000 catheter days as a result of the educational effort (relative risk 0.43; 95% confidence interval (CI): 0.22-0.84). The percentage of subclavian vein CVC insertions increased from 25% to 41% (p<0.001). These findings were accompanied by a decrease in the incidence of sepsis from 16% to 12% (p=0.03). Warren et al. subsequently performed a multicenter trial in 13 ICUs among 6 academic centers to prove that revising existing CVC insertion and care policies as well as implementing educational programs that highlight best practices in CVC utilization improve CLABSI rates (12). After establishing CLABSI rates, the educational process was implemented and infections were followed for the subsequent 18 months. With staff education, the percentage of femoral CVCs decreased from 12.9% to 9.4% (relative ratio 0.73; 95% CI: 0.61-0.88) and the percentage of dated CVC dressings increased from 26.6% to 34.3% (relative ratio 1.29; 95% CI: 1.17-1.42). The overall rate of CLABSI decreased significantly from 11.2 to 8.9 per 1,000 Version 4.0 16 Revised 11/07/2016