Practice Guidelines for Central Venous Access: A Report by the American Society of Anesthesiologists Task Force on Central Venous Access

Abstract

PRACTICE Guidelines are systematically developed recommendations that assist the practitioner and patient in making decisions about health care. These recommendations may be adopted, modified, or rejected according to clinical needs and constraints, and are not intended to replace local institutional policies. In addition, Practice Guidelines developed by the American Society of Anesthesiologists (ASA) are not intended as standards or absolute requirements, and their use cannot guarantee any specific outcome. Practice Guidelines are subject to revision as warranted by the evolution of medical knowledge, technology, and practice. They provide basic recommendations that are supported by a synthesis and analysis of the current literature, expert and practitioner opinion, open forum commentary, and clinical feasibility data.For these Guidelines, central venous access is defined as placement of a catheter such that the catheter is inserted into a venous great vessel. The venous great vessels include the superior vena cava, inferior vena cava, brachiocephalic veins, internal jugular veins, subclavian veins, iliac veins, and common femoral veins.*Excluded are catheters that terminate in a systemic artery.The purposes of these Guidelines are to (1) provide guidance regarding placement and management of central venous catheters, (2) reduce infectious, mechanical, thrombotic, and other adverse outcomes associated with central venous catheterization, and (3) improve management of arterial trauma or injury arising from central venous catheterization.These Guidelines apply to patients undergoing elective central venous access procedures performed by anesthesiologists or health care professionals under the direction/supervision of anesthesiologists. The Guidelines do not address (1) clinical indications for placement of central venous catheters, (2) emergency placement of central venous catheters, (3) patients with peripherally inserted central catheters, (4) placement and residence of a pulmonary artery catheter, (5) insertion of tunneled central lines (e.g. , permacaths, portacaths, Hickman®, Quinton®, (6) methods of detection or treatment of infectious complications associated with central venous catheterization, or (7) diagnosis and management of central venous catheter-associated trauma or injury (e.g. , pneumothorax or air embolism), with the exception of carotid arterial injury.These Guidelines are intended for use by anesthesiologists and individuals who are under the supervision of an anesthesiologist. They also may serve as a resource for other physicians (e.g. , surgeons, radiologists), nurses, or health care providers who manage patients with central venous catheters.The ASA appointed a Task Force of 12 members, including anesthesiologists in both private and academic practice from various geographic areas of the United States and two consulting methodologists from the ASA Committee on Standards and Practice Parameters.The Task Force developed the Guidelines by means of a seven-step process. First, they reached consensus on the criteria for evidence. Second, original published research studies from peer-reviewed journals relevant to central venous access were reviewed and evaluated. Third, expert consultants were asked to (1) participate in opinion surveys on the effectiveness of various central venous access recommendations and (2) review and comment on a draft of the Guidelines. Fourth, opinions about the Guideline recommendations were solicited from a sample of active members of the ASA. Opinions on selected topics related to pediatric patients were solicited from a sample of active members of the Society for Pediatric Anesthesia (SPA). Fifth, the Task Force held open forums at three major national meetings†to solicit input on its draft recommendations. Sixth, the consultants were surveyed to assess their opinions on the feasibility of implementing the Guidelines. Seventh, all available information was used to build consensus within the Task Force to finalize the Guidelines. A summary of recommendations may be found in appendix 1.Preparation of these Guidelines followed a rigorous methodologic process. Evidence was obtained from two principal sources: scientific evidence and opinion-based evidence.Study findings from published scientific literature were aggregated and are reported in summary form by evidence category, as described in the following paragraphs. All literature (e.g. , randomized controlled trials, observational studies, case reports) relevant to each topic was considered when evaluating the findings. However, for reporting purposes in this document, only the highest level of evidence (i.e. , level 1, 2, or 3 within category A, B, or C, as identified in the following paragraphs) is included in the summary.Randomized controlled trials report statistically significant (P < 0.01) differences between clinical interventions for a specified clinical outcome.Information from observational studies per