(PDF) IJCCM 2020 ISCCM positon statement on CVC

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ArticlePDF AvailableIJCCM 2020 ISCCM positon statement on CVCAugust 2020Indian Journal of Critical Care Medicine 24(Suppl1):S6-S30Authors: Sumit RayHoly Family Hospital Delhi Download full-text PDFRead full-textDownload full-text PDFRead full-textDownload citation Copy link Link copied Read full-text Download citation Copy link Link copiedReferences (217)AbstractBackground and Purpose: Short-term central venous catheterization (CVC) is one of the commonly used invasive interventions in ICU and other patient-care areas. Practice and management of CVC is not standardized, varies widely, and need appropriate guidance. Purpose of this document is to provide a comprehensive, evidence-based and up-to-date, one document source for practice and management of central venous catheterization. These recommendations are intended to be used by critical care physicians and allied professionals involved in care of patients with central venous lines. Methods: This position statement for central venous catheterization is framed by expert committee members under the aegis of Indian Society of Critical Care Medicine (ISCCM). Experts group exchanged and reviewed the relevant literature. During the final meeting of the experts held at the ISCCM Head Office, a consensus on all the topics was made and the recommendations for final document draft were prepared. The final document was reviewed and accepted by all expert committee members and after a process of peer-review this document is finally accepted as an official ISCCM position paper. Modified grade system was utilized to classify the quality of evidence and the strength of recommendations. The draft document thus formulated was reviewed by all committee members; further comments and suggestions were incorporated after discussion, and a final document was prepared. Results: This document makes recommendations about various aspects of resource preparation, infection control, prevention of mechanical complication and surveillance related to short-term central venous catheterization. This document also provides four appendices for ready reference and use at institutional level. Conclusion: In this document, committee is able to make 54 different recommendations for various aspects of care, out of which 40 are strong and 14 weak recommendations. Among all of them, 42 recommendations are backed by any level of evidence, however due to paucity of data on 12 clinical questions, a consensus was reached by working committee and practice recommendations given on these topics are based on vast clinical experience of the members of this committee, which makes a useful practice point. Committee recognizes the fact that in event of new emerging evidences this document will require update, and that shall be provided in due time. Discover the world s research20+ million members135+ million publications700k+ research projectsJoin for freePublic Full-text 1Content uploaded by Sumit RayAuthor contentAll content in this area was uploaded by Sumit Ray on Aug 19, 2020 Content may be subject to copyright. Ab s t r A c tBackground and Purpose: Short-term central venous catheterization (CVC) is one of the commonly used invasive interventions in ICU and other patient-care areas. Practice and management of CVC is not standardized, varies widely, and need appropriate guidance. Purpose of this document is to provide a comprehensive, evidence-based and up-to-date, one document source for practice and management of central venous catheterization. These recommendations are intended to be used by critical care physicians and allied professionals involved in care of patients with central venous lines.Methods: This position statement for central venous catheterization is framed by expert committee members under the aegis of Indian Society of Critical Care Medicine (ISCCM). Experts group exchanged and reviewed the relevant literature. During the nal meeting of the experts held at the ISCCM Head Oce, a consensus on all the topics was made and the recommendations for nal document draft were prepared. The nal document was reviewed and accepted by all expert committee members and after a process of peer-review this document is nally accepted as an ocial ISCCM position paper. Modied grade system was utilized to classify the quality of evidence and the strength of recommendations. The draft document thus formulated was reviewed by all committee members; further comments and suggestions were incorporated after discussion, and a nal document was prepared.Results: This document makes recommendations about various aspects of resource preparation, infection control, prevention of mechanical complication and surveillance related to short-term central venous catheterization. This document also provides four appendices for ready reference and use at institutional level.Conclusion: In this document, committee is able to make 54 dierent recommendations for various aspects of care, out of which 40 are strong and 14 weak recommendations. Among all of them, 42 recommendations are backed by any level of evidence, however due to paucity of data on 12 clinical questions, a consensus was reached by working committee and practice recommendations given on these topics are based on vast clinical experience of the members of this committee, which makes a useful practice point. Committee recognizes the fact that in event of new emerging evidences this document will require update, and that shall be provided in due time.Keywords: Central venous catheterization, CRBSI, Infection control, Position statement, SurveillanceAbbreviations list: ABHR: Alcohol-based hand rub; AICD: Automated implantable cardioverter debrillator; BSI: Blood stream infection; C/SS: CHG/silver sulfadiazine; Cath Lab: Catheterization laboratory (Cardiac Cath Lab); CDC: Centers for Disease Control and Prevention; CFU: Colony forming unit; CHG: Chlorhexidine gluconate; CL: Central line; COMBUX: Comparison of Bedside Ultrasound with Chest X-ray (COMBUX study); CQI: Continuous quality improvement; CRBSI: Catheter-related blood stream infection; CUS: Chest ultrasonography; CVC: Central Venous Catheter; CXR: Chest X-ray; DTTP: Dierential time to positivity; DVT: Deep venous thrombosis; ECG: Electrocardiography; ELVIS: Ethanol lock and risk of hemodialysis catheter infection in critically ill patients ; ER: Emergency room; FDA: Food and Drug Administration; FV: Femoral vein; GWE: Guidewire exchange; HD catheter: Hemodialysis catheter; HTS: Hypertonic saline; ICP: Intracranial pressure; ICU: Intensive Care Unit; IDSA: Infectious Disease Society of America ; IJV: Internal jugular vein; IPC: Indian penal code; IRR: Incidence rate ratio; ISCCM: Indian Society of Critical Care Medicine; IV: Intravenous; LCBI: Laboratory conrmed blood stream infection; M/R: Minocycline/rifampicin; MBI-LCBI: Mucosal barrier injury laboratory-conrmed bloodstream infection; MRSA: Methicillin-resistant Staphylococcus aureus; NHS: National Health Service (UK); NHSN: National Healthcare Safety Network (USA); OT: Operation Theater; PICC: Peripherally-inserted central catheter; PIV: Peripheral intravenous line; PL: Peripheral line; PVI: Povidone-iodine; RA: Right atrium; RCT: Randomized controlled trial; RR: Relative risk; SCV/SV: Subclavian vein; ScVO2: Central venous oxygen saturation; Sn: Sensitivity; SOP: Standard operating procedure ; SVC: Superior vena cava; TEE: Transesophageal echocardiography; UPP: Useful Practice Points; USG: Ultrasonography; WHO: World Health OrganizationIndian Journal of Critical Care Medicine (2020): 10.5005/jp-journals-10071-G23183Indian Society of Critical Care MedicinePosition Statement for Central Venous Catheterization and Management 2020Yash Javeri1, Ganshyam Jagathkar2, Subhal Dixit3, Dhruva Chaudhary4, Kapil Gangadhar Zirpe5, Yan Mehta6, Deepak Govil7, Rajesh C Mishra8, Srinivas Samavedam9, Rahul Anil Pandit10, Raymond Dominic Savio11, Anuj M Clerk12, Shrikanth Srinivasan13, Deven Juneja14, Sumit Ray15, Tapas Kumar Sahoo16, Srinivas Jakkinaboina17, Nandhakishore Jampala18, Ravi Jain19GUIDELINES/POSITION STATEMENTS© The Author(s). 2020 Open Access This article is distributed unde r the terms of the Creative Commons Attributio n 4.0 International License (https: //creativecommons.org/licenses/by- nc/4.0/), which permits unrestric ted use, distribution, and non -commercial reproduc tion in any medium, provided yo u give appropriate credit to the original author(s) and the source, prov ide a link to the Creative Commons license, and indicate if ch anges were made. The Creative Commons Pub lic Domain Dedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated. Position Statement for Central Venous Catheterization and Management 2020Indian Journal of Crical Care Medicine, January 2020;24(Suppl 1) S7Corresponding Author: Yash Javeri, Department of Critical Care, Anesthesia and Emergency Medicine, Regency Health, Lucknow, Uttar Pradesh, India, Phone: 91-9818716943, e-mail: dryashjaveri@yahoo.comHow to cite this article: Javeri Y, Jagathkar G, Dixit S, Chaudhary D, Zirpe KG, Mehta Y, et al. Indian Society of Critical Care Medicine Position Statement for Central Venous Catheterization and Management 2020. Indian J Crit Care Med 2020;24(Suppl 1):S6–S30.Source of support: NilConict of interest: NonePreamblePresent document is an evidence based approach towards management of CVC in clinical practice. The recommendations presented in this document are based upon:• Latest available literature on the topic• Various patient safety and institutional manuals • Guidelines policy of national and global bodies• Consensus and experience of expert committee on the topicAfter evaluation of the available literature, this position statement is developed by a representative committee of Indian Society of Critical Care Medicine (ISCCM). This document’s recommendations suggest a preferred approach for management of CVC in healthcare set tings. Simultaneously these recommendations are intended to be exible and sh ould be rationalized to the clinical context. This document is designed as a \"position paper ”, as use of CVCs is not just limited to ICUs and extended to other specialties and patient care areas. However, in its limited sense it sho uld serve an important purpose to provide standardized and high level of safe patient care. After completion of thorough reviews by the committee, this document is ocially endorsed by ISCCM.IntroductIonCentral venous catheterization is o ne of the regularly used invasive procedures in various areas of patient care like intensive care unit, operating room, and emergency depar tment. The practice of CVC varies widely. This document is an attempt to suggest a safe and preferred strategy for CVC.For standardization in this document, National Healthcare Safety Net work (NHSN) denition of central line has been adopted. NHSN denes \"Central line (CL), as an intravascular catheter that terminates at or close to the heart, or in one of the great vessels that is used for infusion, withdrawal of blood, or hemodynamic monitoring.”1For all practical purposes in this present document, \"Central Venous Catheter” is dened here as a central line placed in one the large venous great vessel, which include internal jugular vein (IJV), brachiocephalic vein, subclavian vein (SCV), superior vena cava (SVC), iliac vein, femoral veins, inferior vena cava (IVC).” This denition has been simplied for easy understanding.Central venous catheterization h ave been classied by various ways like the vessels it occupies, site of insertion, duration of use, its path from skin to vessel, material, special coatings, physical length, number of lumens or some special characteristic and uses of catheter. During the discussion all of these aspects have been considered but this docume nt remained focused on short-term use of CVCs in adult patients . During the discussion all long term CVCs, tunneled catheters, H D catheter, PICC, Hickman catheter, peripheral cannula, pediatric patient p opulation and catheter terminating in a systemic artery and pulmonary arteries were not reviewed.Pu r P o s e a n d s c o P eThe purpose of this docu ment is to provide a preferred strategy for: • Judicious use of CVC• CVC placement and management• Reduce mechanical, infec tious, and thrombotic complications • Provide guidance to improve CVC care qualityThese recommendations are intended for use by critical care physicians and other professionals involved in care of patients wi th central venous line. This also ser ves as a resource for other care areas who manage patients with short-term central venous catheters.me t h o d s a n d e v I d e n c e d e v e lo P m e n tThis position statement for CVC is framed by expert committee members under the aegis of ISCCM. After multiple rounds of meeting of team of experts in the eld, the consensus was derived on the scope and questions that needed to be answered in the formulation of this document. The team of experts was assigned the task of literature review in divided sections of the document. Search for relevant literature was performed by probing various electronic databases including Google Scholar, PubMed, and Embase. Following keywords were used to formulate search strategy: Arte rial catheter, antibiotic lock, bacteremia, central lines, central venous catheter, catheter-related cultures, endocarditis, implanted catheter, management, non-tunneled, outbreak. Peripheral, suppurative thrombophlebitis, and treatment—other references from arti cles and major contemporary guidelines on the topic were also reviewed.Experts in each group then exchanged and reviewed the relevant literature. During the nal meeting of the experts held at the ISCCM head oce, a consensus on all the topics was made and the recommendations for nal do cument draft were prepared.Modified grade system was utilized to classify the quality of evidence and the strength of recommendations (Table 1). For semantic separation of strong and weak recommendations, the working group has introduced each strong (grade A) recommendation by \"we recommend” and each weak (grade B) recommendation by \"we suggest” terminologies.The draft document thus formulated was reviewed by all committee members; further comments and suggestions were incorporated af ter discussion, and a nal docume nt was prepared. The final document was reviewed and accepted by all expert committee members and after a process of peer review this document is nally accepted as an ocial ISCCM position paper.re co m m e n d a t I o n s a n d ev I d e n c e s t at e m e n t sTable 2 here provides summary of recommendation provided in this documents. A detailed description of all recommendations is in the following discussion.resource P r e Pa r at I o nIndications of Central Venous CatheterizationEvidence StatementCentral venous catheterization is a vital procedure in care of a critically ill patient. There are various indications for use of CVC Position Statement for Central Venous Catheterization and Management 2020Indian Journal of Crical Care Medicine, January 2020;24(Suppl 1)S8Table 1: Criteria for level of evidence and grading of strength of recommendations used in formulation of present document.Quality of evidence LevelEvidence from ≥1 good quality and well-conducted randomized control trial(s) or meta-analysis of RCT’s 1Evidence from at least 1 RCT of moderate quality, or well-designed clinical trial without randomization; or from cohort or case-controlled studies2Evidence from descriptive studies, or reports of expert committees, or opinion of respected authorities based on clinical experience 3Not backed by sucient evidence; however, a consensus reached by the working group, based on clinical experience and expertise Useful Practice Point (UPP) Strength of recommendations GradeStrong recommendations to do (or not to do) where the benets clearly outweigh the risk (or vice versa) for most, if not all patients AWeak recommendations, where benets and risk are more closely balanced or are more uncertain BTable 2: Recommendations list of Indian Society of Critical Care Medicine Position Statement for Central Venous Catheterization and Management 2020.S/no. Statement GOR, LOE1. Resource preparationA. Indications of central venous catheterization1 We recommend central venous catheterization after understanding clear indication A, 32 We suggest CVC when hyperosmolar and locally irritant agents are to be administered B, UPP3 We recommend CVC use for vasoactive drugs unless the risk outweighs benet of placing a CVC and delaying the therapyA, 3B. CVC catheterization in locations other than ICU1 We recommend that care areas, where CVC is utilized should have a central venous cannulation and maintenance SOP in accordance with recommendations made in this documentA, UPP2 We recommend that all units performing central venous cannulation should have a quality improvement program in place with follow-up of outcomesA, UPP3 We recommend that daily review for the necessity of CVC should be done at all care sites A, 2C. Central venous catheter site selection1 We recommend In emergency scenarios, insertion site selection should be based on patient factors, clinical need, practi-tioner judgment, experience and skillsA, 32 We suggest subclavian insertion site should be preferred over IJV and femoral for central venous catheterization to decrease infectious and thrombotic complicationsB, 23 We recommend subclavian vein to be avoided in patient with coagulopathy, distorted anatomy, and who may have high chances of mechanical complicationsA, 24 We recommend that in case of burns, extensive skin loss and supercial infections, CVC insertion should be done where the skin is intactA, UPP5 We suggest Internal Jugular CVC lines could safely be inserted in adult neurocritical care patients B, 2D. Catheter selection1 We suggest to use a CVC with the minimum number lumens needed for patient management B, 32 No recommendation can be made for designated lumen for parenteral nutrition. Unresolved issue B, 32. CVC—Infection controlA. Site selection1 We suggest evaluating risk-to-benet ratio of infectious and mechanical complications before choosing a particular insertion siteB, 22 We recommend avoiding using femoral vein for the routine placement of central venous catheters A, 2B. Hygiene practices, barrier precautions, and skin preparation1 We recommend mandatory hand hygiene practice, either by washing hands with conventional soap and water or with alcohol-based hand rub (ABHR), before and after any interventions or contact with CVCA, 22 We recommend maintaining aseptic technique for insertion and maintenance of CVC A, 2contd... Position Statement for Central Venous Catheterization and Management 2020Indian Journal of Crical Care Medicine, January 2020;24(Suppl 1) S93 We recommend maximal sterile barrier (MSB) precautions before any insertion (de novo or exchange over guidewire) of CVCA, 14 We recommend wearing either clean or sterile gloves when handling or dressing the CVC A, 35 We recommend preparation and cleaning of the skin site with an alcoholic chlorhexidine solution containing a concen-tration more than 0.5% chlorhexidine and 70 % alcohol before central venous catheter insertion and during dressing changesA, 16 We suggest to use tincture of iodine, an iodophor, or 70 % alcohol use as alternatives if chlorhexidine is contraindicated B, 37 We recommend allowing the skin antiseptic to dry completely before catheter insertion A, 2C. CVC Fixation1 No recommendation can be made for preference of securing system and operator or local practice based decision should be taken.B, 3D. Port utilization and maintenance1 We recommend disinfecting catheter hubs, needleless connectors, taps and injection ports before accessing the cath-eter using an alcoholic chlorhexidine preparation or 70 % alcoholA, 22 We recommend wearing either clean or sterile gloves when handling the hub and catheter A, 3E. Prophylactic antibiotics and antiseptics1 No recommendation can be made for or against the use of antiseptic solutions (Aqueous chlorhexidine or aqueous povidone-iodine] for routine CVC site careA, 32 We recommend the use of chlorhexidine soaked sponge or dressing at the catheter exit site to prevent CRBSI A, 13 We recommend daily Chlorhexidine Bed Bath[sponging] for patients in ICU to reduce CRBSI incidence A, 14 We suggest antibiotic lock solutions to prevent CRBSI only in selected conditions, which are as follows:a) Limited or dicult venous access and a history of recurrent CRBSI b) At high risk of severe sequelae from a CLABSI (e.g., recently implanted intravascular devices, such as prosthetic heart valve or aortic graft, pacemaker or AICD)c) When CRBSI rate is high despite all measures to reduce it are implemented stringentlyB, 25 We recommend against systemic intravenous antibiotics in prevention of CRBSI A, 1F. Removal of Central line1 We recommend removing central venous catheter as soon as its indication ceases A, UPP2 We suggest not routinely replacing or relocating the central venous lines unless clinically indicated B, UPP3 We recommend each institute to have central venous catheter removal protocol and only sta trained in the same should remove central lineA, UPPG. Catheters impregnated with antiseptics and antibiotics1 We recommend using M/R or C/SS coated CVCs when catheter is expected to be in use for more than ve days and the CLABSI rate is not decreasing to the institutional target benchmark even after implementing comprehensive strategy program. Comprehensive strategy should include education and training, maximal barrier precaution and aseptic skin preparation while insertion of CVC.A, 13. Prevention of mechanical complicationsA. Role of sonography1 Wherever available we recommend US guidance to improve success rate, patient safety and procedural quality and reduce mechanical complications during CVC placementA, 2B. Guidewire exchange1 We suggest exchange of malfunctioning CVC over guidewire in selected patients with no evidence of infection B, 2C. Tip positioning1 We recommend post-procedure, position of the catheter tip must be assessed A, UPP2 We recommend IJ and SCV catheter tip should be placed in the lower one-third of the SVC near the SVC/RA junction A, 23 We recommend the use of chest X-ray to assess the CVC catheter tip position A, 24. SurveillanceA. Infection control1 We recommend against routine replacement of CVCs to prevent catheter-related infections A, 12 We recommend prompt removal of CVC when it is not essential A, 2contd...contd... Position Statement for Central Venous Catheterization and Management 2020Indian Journal of Crical Care Medicine, January 2020;24(Suppl 1)S103 We recommend against routine catheter tip cultures for purpose of surveillance A, 24 We recommend that routine practice bundle (Appendix II) should be followed to reduce CVC-related infections. A, 1B. Surveillance of mechanical complications1 We recommend Chest X-ray post insertion of IJ and SC central line A, 22 We suggest that ultrasound guidance can be used for early identication of mechanical complication B, 2C. Education, training, CQI initiatives, and audit Education and training1 We recommend that a healthcare education and training program should be in place wherever CVCs are inserted and maintained for overall quality improvementA, 12 We recommend that a mechanism should be in place to assess knowledge and compliance with guidelines of all the personnel involved in care related to CVCA, 13 We suggest providing appropriate and adequate nursing care to improve CVC-related outcomes B, 2 CQI initiatives1 We recommend using institutional CQI initiatives with bundled approach for performance improvement A, 2 Audit tools1 We recommend conducting surveillance to determine CLABSI rates, monitor its trends and identify lapses in infection control practicesA, 12 We do not recommended routine culture of catheter tip for purpose of surveillance A, 13 DTTP is the recommended method of diagnosis for CVC-related infections in patients A, 24 We suggest recording the operator, date and time of catheter insertion and removal and dressing changes on a stand-ardized formA, UPPD. Consent and medicolegal issues 1 We suggest that a structured Credentialing process be in place for personnel involved in insertion and maintenance of CVCB, UPPcontd...and we reviewed each indication systematically for purpose of standardization and uniformit y. The recommended indications are as below, but the list is not exclusive and judicious justication by user is recommended.Central venous catheterization as means of vascular accessCentral venous cannulation is indicated as means of vascular access for patients with dicult intravenous access, those re quiring multiple attempts fo r peripheral access, obese patients with di cult peripheral access and patients with other chronic conditions.2Central venous cannulation for vasopressors and inotropes administrationCentral venous access should be chosen for administration of vasopressors and inotropes required for prolonged duration ( 4 hours).3Few small descriptive observati onal studies and review articles suggest safe use of peripherally administered vasopressors; however, a systematic review of descriptive studies w hich included 85 articles, had 270 patients and 325 events of local tissue injury and extravasations occurred.3 On further evaluation, it was noted that majority of events occurred when vasopressors used with peripheral lines (318/325 events). Out of which 204 events had local injury and 114 events had extravasation. These events were not generally associated with major disability and harm, as they occurs in 5% chances, with mortality chances of 2.2% . In further description it was found that 85.3% local tissue injury occurred when vasopressor were given via a distal peripheral venous lines than the popliteal or antecubita l fossae (e.g., dorsal hands, forearms, feet), and in 96.8% occurred when infusion continued for 4 hours or more. Same results were observed for extravasation, as 75% events occurred due to a distal peripheral line. Hence, based on these ndings of studies and me ta-analysis, vasopressors infusions cannot be recommended to be used via peripheral line.However, the expert committee recognizes that in compelling situations, vasopressor infusions for a short duration ( 4 hours) via a more proximal vein (in antecubital fossa or external jugular vein) can be used without causing major harm, especially when a CVC is planned and risk of delaying therapy outweighs the benet.3 -7Central venous cannulation for administration of parenteral nutritionHigh osmolarity liquids cause damage of endothelium and f urther lead to thrombophlebitis of peripheral vein hence central venous cannulation can be considered for administration of parenteral nutrition with osmolarity 900 mOsm/L. However, commercially available parenteral nutrition with osm olarity of up to 900 mOsm/L can be administered and tolerated peripherally.8 Drugs to be given through central venous cannulationNeed for central venous cannulation for any drug administration depends on factors like osmolarity of the drug, pH of drug, and direct cytotoxicity of drug. Central venous catheterization should be considered for infusion of dru gs with osmolarity of 600 mOsm/L and pH of less than 5 or greater than 9, if requiring continuous infusion at high rate or repeated infusions.9 Position Statement for Central Venous Catheterization and Management 2020Indian Journal of Crical Care Medicine, January 2020;24(Suppl 1) S113% NaCl and 20% mannitol administration 3% NaCl and 20% mannitol both are drugs with high osm olarity as 1,026 mOsm/L and 1,098 mOsm/L, respectively. Mandatory centr al venous cannulation for administratio n of these drugs is institutional practice, as central line insertion might be time consuming specically in some time sensitive situations like patient with head injury with cerebral edema.Although some studies suggest safe use of 3% NaCl through large bore periphe ral cannula (16–20 G) at maximum rate of 50 mL/hour.10 In one prospective study patients were subjected to 3% hypertonic saline (HTS) infusions for prolong time for several days which resulted in inltration (6%), and thrombophlebitis (3%). These studies indicate that concern regarding p eripheral intravenous (PIV) 3% HTS infusion may be exaggerated. Further it carries a low risk of serious limb, or life-threatening complications, and hence the committee recognizes that a patient can be subjected to it if the benet outweighs the risk.11 However, further research is needed for safe peripheral infusion of 20% mannitol, and this issue was unresolved.Potassium infusionPotassium infusion of maximum concentration 10 mEq/100 mL can be given via peripheral IV lines. Replacement via CVC may be required at higher concentrations and at higher rate for better uid tolerance and rapid correction. Available potassium ampoule contains concentrated potassium solution at osmolarity of approximately 4,000 mOsm/L (2 mEq/mL of potassium). This needs to be diluted and infused slowly via central venous cannulation (maximum recommended concentration 20 mEq/50 mL). Administration through central cannula helps to thoroughly dilute the solution in blood stream and also decrease the risk of extravasations and avoid pain and phlebitis associated with peripheral administration.Amiodarone administrationPractice of administration of IV amiodarone infusion also depends upon institutional protocols and has many issues. Injection amiodarone has pH of 3.5 –4.5 which is highly irritant to peripheral veins. Amiodarone has tendency to form precipitates at normal pH of blood and responsible for thrombophlebitis when infusion given through peripheral vei n. For these reasons when amiodarone infusion is required for more than 1 hour and at concentration of more than 2 mg/mL, central venous cannulation is prescribed by some institutions.CVC can be considered for other drugs such as continuous infusion of sodium bicarbonate solution (osmolality of ~2000 mOsm/kg), continuous infusion of 20% dextrose infusions (osmolarity 1200 mOsm/L), etc. An institutional protocol for such infusions is recommended.co n c lu s I o nIn general CVC is indicated for vascular access, vasopressor infusions, hyperosmolar and irr itant infusions. However, the drafting committee unanimously agrees to the fact that, whenever a CVC is planned, documentation of its indication is necessary to be maintained in clinical records and benet of placing a CVC should outweighs its risk. Recommendations• We recommend CVC after documenting its indication [A, 3].• We suggest CVC when hyperosmolar an d locally irritant agents are to be administered [B, UPP].• We recommend CVC’s use for vasoactive drugs unless the risk outweighs benet of placing a CVC and delaying the therapy [A, 3].CVC Catheterization in Locations other than ICUEvidence StatementCentral venous catheterization is done frequently in many other locations like emergency rooms (ER), operation theaters (OT), cardiac catheterization labs (Cath Labs), procedure rooms, etc. The practice and various o utcomes related to CVC vary widely according to the user location in hospital. CVC placement in emergency departmentCentral venous catheter placement in ER is used for various indications such as resuscitation of sepsis in patients to guide CVP and ScVO2 monitoring,12-14 hyperosmotic infusions and diculty in securing a peripheral venous access.15 However, in the recent years, growing evidence has questioned the validity of all of the above-mentioned indications in ER. Recently performed major trials have challenged the role of EGDT refuting the routine monitoring of CVP and ScVO2 while resuscitating a septic patient.16 Likewise, assessment for preload and its responsiveness has moved far from CVP.17 There is also the fear of breach of infection control practices in an emergency and a possible higher incidence of CLABSI.18,19 The greater use of ultrasound for peripheral intravenous access has further obviated the need for central lines20 in instances of dicult access.Also as evidence have been evaluated in previous section of indications, it seems prudent to state that hyperosmolar or vasoactive infusion are also fairly safe while administered in appropriate dilution and for short periods through a well-placed wide bore peripheral venous access.21,22 Most of the available literature with regards to CVCs placed in the ER is datasets which are not globally representative. Needless to say, the outlook for CVC practice in an ER depends on various factors, notably, the ER infrastructure, stang pattern, experience of emergency physician, presence of SOPs, etc.23 Generating a strong evidence-based guideline as to whether placing CVCs in the ER is warranted, is virtually imp ossible. While the importance of the \"Golden Hour” and \"Initial Stabilization” cannot be neglected, practices and concepts have perhaps moved away from the CVC for reasons discussed earlier.16-22 Moreover, the paradigm shift from landmark guided to USG-guided cannulation24-2 6 and requirement for stringent infection prevention measures27 raises caution in resource limited and emergent settings. It may be prudent to avoid CVCs in the ER, unless strongly indicated. The same applies to CVC placement in other areas including ICU. Those units which perform central venous cannulation should have a rigorous qualit y improvement program with ongoing training and follow-up of outcomes.19,28,29 Due consideration should be given for prompt removal of an emergently placed CVC if breach of aseptic precautions have occurred.30 Position Statement for Central Venous Catheterization and Management 2020Indian Journal of Crical Care Medicine, January 2020;24(Suppl 1)S12CVC placement in wardPlacement of central venous catheters in the ward/rooms is fraught with multiple challenges including—(1) monitoring during insertion, (2) adherence to infection prevention bundles, (3) availability of bedside ultrasound, (4) availability of trained assistant/nurse, etc. Furthermore, ambulatory patients present with more unique challenges to post-insertion care. The common indications in this patient population are prolonged antibiotic therapy, dicult peripheral venous access, or for chemotherapy.31 We presume that the complication rates, both infective and non-infective could be higher for CVCs inser ted outside acute care areas as no large studies or database exists to support this conviction. Surveillance and benchmark data for out-of-ICU CLABSI are gradually emerging.32 Site of insertion should b e guided by factors such as (1) level of care, (2) resource availability, (3) patient population, etc. At this time point, it may be dicult to restric t CVC insertion to acute care areas. CVCs may be inserted in the wards provided all necessary prec autions are strictly adhered to.33 Daily documentation for the need to continue CVC is to be mandated as a means of avoiding unnecessary line days and CL ABSI.34,35 Recommendations pertaining to monitoring, inf ection, prevention and management, audit tools and medicolegal liabilities described elsewhere in this document will apply universally even to CVCs placed in the wards. CVC placement in procedure roomsThere is insucient evidence at this juncture to suggest if CVC placement in dedicated pro cedure rooms has clinical implications. The whole idea of procedure rooms revolves around the concept of providing a comfortable and organized environment where aseptic procedures can be s afely performed. H owever, standardized infection control pr actices, equipment, and monitoring facili ties are mandatory for procedure rooms.36-39 co n c lu s I o nCentral venous catheterization is done frequently in many other locations like emergency rooms (ER), operation theaters (OT), cardiac catheterization labs (Cath Labs), and procedure rooms etc. Institutional polic y with standard operating procedure (SOP) should be available. Adequate preparation and training is desired for all those involved in insertion and maintenance of CVCs.Recommendations• We recommend that all site of care, where C VC is utilized should have a central venous cannulation and maintenance SOP in accordance with recommendations made in this document [A, UPP].• We recommend that all units performing central venous cannulation should have a quality improvement program in place with follow-up of outcomes [A, UPP].• We recommend that daily review for the necessity of CVC should be done in the wards [A, 2].Central Venous Catheter Site SelectionEvidence StatementAs already mentioned, CVC can be placed in veins in the neck (IJV), chest (SCV or axillary vein), groin (femoral vein). These sites can be selected on the basis of ease of placement, individual expertise and on the associated procedural risk, and other clinical variables. We examined the evidences for comparison of each site.Site Selection in Emergent Conditions3SITES study, a RCT, randomized approximately 3,000 patients to dierent groups to have CVC placed in the subclavian, jugular, or femoral veins.40 They concluded that lines in SCV were associated with a lower CRBSI risk and thrombotic complications then lines in IJV or femoral vein. Simultaneously, they also found that SCV lines were also associated with highest mechanical complications among the three sites. SCV lines are associated with three times more risk of pneumothorax then the IJV option, whereas femoral lines eliminates pneumothorax risk, and comparable to the IJ in infection risk, but has signicant DVT risk.Although, SCV lines are safer in terms of infection and thrombotic complication risks but have commoner mechanical complications which may have serious consequences.41 Although choosing SCV is preferable for any catheter intended to be used for more than 5 days, but in emergent conditions such as severe hypoxia or coagulopathies, femoral CVC are associated with an acceptable complications rate, esp ecially if strict aseptic techniques are used while insertion.42IJV versus subclavian central venous cannulationWhile comparing IJV and SCV sites for CVC cannulation the committee reviewed ease o f access, mechanical complication rates, malposition and its complications, and infectious complications closely.Literature review concludes that in comparison to SCV, IJV access is much easier and less technically demanding with the use of USG guidance.41 Malpositioning with IJV approach is less common then in SCV approach.43 Simultaneously, a meta-analysis by Ruesch et al. including six trials, 1,299 catheter, conclude that malposition events were signic antly less common and less serious with jugular approach.44 In same analysis, SCV approach had less frequent accidental arterial punctures then IJV. However, control over carotid artery bleeding is easier than subclavian artery. In this analysis, hemothorax or pneumothorax complications were similar with both IJV and SCV approach. However, in other recent prospective stud y by Iovino et al. there was signic antly low risk of pneumothorax in IJV app roach then in SCV approach. These results are similar to the results of three sites study where mechanical complications were far more common with SCV then IJV.40,45,46Thrombosis of IJV was more common than thrombosis of SCV. Large bore CVC insertion has increased risk of thrombosis and subsequent occlusion especially in subclavian vein.As quoted before, 3SITES study concluded that infectious complications were less with SCV than IJV and hence, the SCV approach is preferred for CVC placements.IJV and SVC versus femoral linesAs the local flora density is different in each common site of insertion for C VC, site selection also inuences the risk of infec tion. In a randomized study of 270 catheters found that femoral site has a higher colonization rate in comparison to SCV (RR: 6.4 [95% CI: 1.9–21.2] but without any increase in BSI (RR: 2.0 [95% CI: 0.2–22.1]). However, multivariate analysis of several prospective studies reported frequent infectious complications when using femoral or IJV sites.47The subcutaneous cour se of the SCV CVC is longer than for the other sites and it has lowest bacterial bio-burden and it is better Position Statement for Central Venous Catheterization and Management 2020Indian Journal of Crical Care Medicine, January 2020;24(Suppl 1) S13protected against dislo dgement of dressing. SCV catheters are also associated with less chances of venous thrombosis.48Femoral catheterizatio n was associated with a higher incidence rate of overall infectious complications, as well as of overall thrombotic complications and complete vessel thrombosis.In this study, SCV site was associated with less infectious complications (1.3 compared to 2.7 per 1,000 catheter days for other sites, incidence density ratio 0.50, 95% CI (0.33–0.74), p 0. 001).48Incidence of mechanical complications—pneumothorax in subclavian catheterization:Subclavian vein catheterization was associated with a higher risk of pneumothorax than femoral vein catheterization.40Special situationsSevere coagulopathyDuring SCV catheterization, bleeding from the SC artery is very dicult to control by compression and often it goes undetected because hematoma may track into the mediastinum or pleural cavity. Hence, SCV is generally the least suitable approach for CVC in patients who are on anticoagulant therapy, and other sites may be preferred.49Patients with burn, extensive skin loss and supercial infectionsIn case of burn patients, extensive skin loss and superficial infections, and site of CVC insertion should be preferred where skin is intact.In a study, even femoral approach for C VC placement does not increase the incidence of C VC colonization in massive burn patients. However, use of anti-microbial impregnated CVCs may be helpful in reducing colonization.50CVC in adult neurocritical care patients who are at risk of high intracranial pressureMany practitioners used to believe that IJV CVC can increase the risk raised ICP in neurocritical care patients. Major physiological reason is that right side IJV serves as the major drainage point for cerebral blood ow, and any kind of obstruction by thrombosis or hematoma or vascular spasm can lead to reduced cerebral blood drainage, poor CSF absorption in cerebral venous blood and so raised ICP.51,52A study Goetting et al. failed to demonstrate any signicant rise in ICP with use of jugular bulb catheterization in 37 pediatric neurocritical care pati ents many other small studies demonstrated the safety of unilateral IJV CVC in neurocritical care patients.53co n c lu s I o nThe committee recogni zes the fact that emergent situation can arise at any location and all due precautions sh ould be taken to maintain a sepsis .We suggest that femoral line is preferred and safer route for CVC insertion during emergency situation for a short-term use.In elective scenarios, S CV insertion has an edge over other sites as it has low risk of infectious and thrombotic complication. The expected duration of catheter use is also important, as cumulative risk of infections and vessel thrombosis increases with increasing number of days. One should consider the fact that mechanical complications can be controlled by use of USG guidance and physician e xperience but infectious and thro mbotic complications cannot be diminished. Thus an ideal site for CVC inser tion does not exist and decisions for the choice of insertion site sho uld be considered on a case-to- case basis by the operator.For neurocritical care patients, current evidence does not reject use of unilateral IJV CVC.Recommendations• We recommend in emergency scena rios, insertion site selection should be based on clinical need, patient factors, practitioner judgment, experience, and skills [A, 3].• We suggest subclavian insertion site should be preferred over IJV and femoral for central venous catheterization to decrease infectious and thrombotic complications [B, 2].• We recommend subclavian vein to be avoided in patient with coagulopathy, distorted anatomy, and who may have high chances of mechanical complications [A, 2].• We recommend that in case of burn, extensive skin loss and supercial infec tions, CVC insertion should be don e where the skin is intact [A, UPP].• We suggest internal jugular CVC lines could safely be inserted in adult neurocritical care patients [B, 2].Catheter SelectionEvidence Statement Central venous catheters have physical variations like length, coating, number of lumens, and types of material. The committee here reviewed the relevant literature to suggest its recommendations.Central venous catheters are comme rcially available from single lumen to ve lumens for various needs of patients. This fact that there may be positive correlation with infection risk to number of lumen has been evaluated in many observational studies. Hilton et al. (1988), they compared infection rates of 502 catheters and found out that infection rate of single lumen catheter was 8% whereas triple lumen catheter was 32%.54 In another randomized observational s tudy, a total of 204 patients and C VC catheters were observed for infe ctious outcomes. Only 177 were able to complete 7 days of therapy, among those 78 patients were randomized to single lumen catheter and 99 patients were randomized for triple lumen catheters, for administration of total parenteral nutrition. Incidence of catheter-related sepsis was 2.6% in single lumen to 13.1% in triple lumen. 55 In other prospective, observationa l studies reported here th e researcher ultimately concluded that number of lumen have a correlation with infecti ous complication with CVC.56, 57co n c lu s I o nAfter reviewing the relevant literature the committee suggested that CVC with minimum number of lumens required should be inserted.Recommendations• We suggest using a CVC with minimum number of lumens needed for patient management whenever feasible [B, 3].• No recommendation can be made for a dedicated lumen for parenteral nutrition. Unresolved issue [B, 3].CVC— I n f e c t I o n co n t r o lSite SelectionEvidence StatementAs discussed in previously, infection is one of the most important care dening outcomes.58 ,59 Infection control strategies ranges Position Statement for Central Venous Catheterization and Management 2020Indian Journal of Crical Care Medicine, January 2020;24(Suppl 1)S14from the modications in insertion technique to use of USG and selecting a site less prone to colonization and infection.60 As this is one of the challenging task to reduce CL-related BSI in ICU, the committee here examined and complied various practice- related topics to reduce infectious complications in CVC.As various evidences e xamined in subheading C of Section 1, it is by now clear that SCV approach have least risk of loc al skin and CVC colonization and also related BSI. 47 This may be attributed to longer subcutaneous course or lowes t bacterial bio-burden related to SC V approach.48 Femoral approach has a higher incidence rate of overall infectious complications and of major infectious complications.48 However, the preferred site for the placement of a central venous catheter depends on multiple factors such as availability of the selected site, operator expertise, infrastructure and availability of ultrasound, clinical urgency, and risk factors for complications like coagulopathy, pneumothorax, etc. In 2011, the Centers for Disease Control and Prevention (CDC) had given a class 1A recommendation against the use of femoral vein for central venous cannulation to decrease the risk of CRBSI.30 However, a systematic review and meta-analysis by Paul E Marik questioned the grading of this recommendation and concluded that there was no dierence in the rates of CRBSI between the three commonly used sites for CVC placement.61 In 2015, a French multicenter randomized controlled study comparing the three dierent sites suggested a reduction in the incidence of CRBSI when subclavian vein was used as compared to the femoral vein. This trial also highlighted the higher risk of pneumothorax with subclavian vein cannulation, a nding similar to other studies.40 A recent meta-analysis by Kostoula Arvaniti showed inconclusive evidence on the CRBSI risk for various sites.62 co n c lu s I o nIn light of recent evidences suggesting reduced or comparable infectious complication w ith femoral approach, the committee still upheld the previous view of discouraging femoral lines to reduce CRBSI burden. As the suppor ting data is pooled form western world and its relevance in Indian scenarios is very questionable. After a thorough discussion and evaluation of all the available literature, the committee was able to formulate following recommendations related to site selection in context to infectious complications.Recommendations• We suggest to evaluate risk-to-benet ratio of infectious and mechanical complications b efore choosing a particular site for catheter insertion [B, 2].• We recommend to avoid using femoral vein for the routine placement of central venous catheters [A, 2].Hygiene Practices, Barrier Precautions, and Skin PreparationEvidence Statement Standard hygiene practices, barrier precautions and preparation before inserting a CVC is one of the most crucial step towards infection control.Hygiene practicesHand hygiene and aseptic techniques, before insertion or during maintenance of CVC, is most important for prevention of infections.63 Adequate hand hygiene can also be achieved by the use of either an alcohol-based hand rub (ABHR)64 or with standard soap and water rinsing.65-67Barrier precautionsMaximum sterile barrier (MSB) precautions are primary requirements during each CVC placements. MSB precautions are dened as wearing a cap, sterile gown, sterile gloves and face mask, and also using a full body drape (similar to the drapes used in the operating room). MSB have been compared in a RCT with small drape and sterile gloves, where MSB has been proven to better in term of catheter colonization and CRBSI rates. With MSB-CRBSI developed much later with gram-ne gative organisms C/F to sterile gloves and small drape group.68 Simultaneously, many other studies revealed that MSB help in reducing skin coloniz ation, and ultimately reduced CSB.69 -72Skin preparationStudy by Yasuda et al.73 compared 3 groups, 0.5% alcohol/CHG solution with 79% ethanol, 1.0% alcohol/CHG solution with 79% ethanol, and 10% aqueous povidone-iodine (PVI). In this study catheter-tip colonization incidence (per 1,000 catheter-days) was found to be 3.7, 3.9, and 10.5 events, respectively (p = 0.03). Pairwise comparison betwee n groups showed that the risk was signicantly higher in the 10% PVI group. However, there were no signicant dierences in colonization risk in both CHG groups. Catheter kept for ≥72 hours had a greater risk of colonizatio n in the 10% PVI group than that in the 0.5% CHG group. However, there were no statistical signicant dierences for probability of developing CRBSI among the groups.73Current CDC guidelines for preventing CRBSI published in 201130 also recommend skin pre paration with 0.5% chlorhexidine gluconate solution with alcohol before insertion of a CVC. co n c lu s I o nNeedless to state, why these precautions are now standard of practice worldwide? These p ractices have become the basic ethics of procedural interventions. With respect to CVC and prevention of infectious complication these practices along with education and training makes the corner stone of CRBSI prevention bundle. Other contemporary international literature also recommends its mandatory implementation before trying any novel approach to reduce CRBSI rates.RecommendationsHygiene practices• We recommend mandatory hand hygiene practice, either by washing hands with conventional soap and water or with ABH R, before and after any interventions or contact with CVC [A, 2].• We recommend maintaining aseptic technique for insertion and maintenance of CVC [A, 2].Barrier precautions• We recommend MSB precautions be fore any insertion (de novo or exchange over guidewire) of CVC [A, 1].• We recommend wearing either clean or sterile gloves when handling or dressing the CVC [A, 3].Skin preparation• We recommend preparation and cleaning of the skin with an alcoholic chlorhexidine solution containing a concentration Position Statement for Central Venous Catheterization and Management 2020Indian Journal of Crical Care Medicine, January 2020;24(Suppl 1) S15more than 0.5% chlorhexidine and 70% alcohol before CVC insertion and during dressing changes [A, 1].• We suggest to use tincture of iodine, an iodophor, or 70% alcohol use as alternatives if chlorhexidine is contraindicated [B, 3].• We recommend allowing the skin antiseptic being used to dry completely before catheter insertion [A, 2].CVC FixationEvidence StatementTraditionally, short-term CVCs are xed to skin with the help of sutures. Skin sutures are respo nsible for local microbial colonization and later on infectious complications. Commercial devices are available for securement purpose like anchor devices, staples, catheter holders, adhesive tapes, locking device, etc., hence it needs a critical evaluation to compare them in terms of related complications, safety, and feasibility.In 2015, Cochrane review for dressing and sec urement devices, 22 studies with 7,436 patients were included.74 These patients had a CVC and nine dierent types of securement device or dressing. After a multiple treatment meta-analysis, in this review authors concluded that suture less securement devices are likely to be the most eective at reducing CRBSI though the quality of evidence is very low and most of these studies were conducted in intensive care unit (ICU) settings. A common perception indee d exists that infections risk are low but malposition and dislodgement risks increases with suture less systems. A recently published international RCT, 186 patients who were treated with help of a CVC, randomized to receive suture (n = 87) or suture free (n = 97) securing device.75 They were analyz ed for CVC migration and unplanne d CVC removals. This study concludes that these two systems performed similarly.Similarly in a Spanish RCT, study group found that complicati ons rate was higher with suture group (47.2%) versus suture less group (21.3%), and also there were signicantly higher loc al complications like signs of infection, oozing and CRBSI in suture group. Also dressing change for local bleeding was lesser in adhesive device group and sta preferen ce was very high towards adhesive device.76In another interesting in vitro study, comparing various suturing methods only the observer found that \"nger trap xation” by suture technique increases dislodgement force signicantly.77co n c lu s I o nWe recognize that all the presented literature has an element of signicant observer bias and there is no concrete and consistent data supporting o r refuting suture based or suture less technique in all clinical contexts, an d further good quality research is ne eded to evaluate this aspect of care. In presently available literature, at one side infectious and local complication were lower with suture less techniques, on another side risk of malposition and dislodgement increases without sutures. In such a scenario where dislodgement is one of a serious concern then \"nger trap xation” by suture can be considered. Recommendation• No recommendation can be made for preference of securing system in each setting and an operator or loca l practice-based decision should be taken into consideration [B, 3].Port Utilization and MaintenanceDenition of hub refers to the end of the CVC that connects to the blood lines or cap. The hubs on CVCs are a common s ource of bacterial colonization and can result in CLABSI.78There are two impor tant aspect of care, to reduce intraluminal contamination; one is to ensure MSB precautions during catheter insertion and two is adequate hub disinfection prior to administration of intravenous medication.79, 80 Adequate hub disinfection here refers to, rubbing hub for at least 10 seconds with chlorhexidine, povidone iodine, an iodophor, or 70% alcohol followed by a drying time of 30 seconds.81 Study by Helder et al. demonstrated 35% nurse’s compliance with the 30 seconds dr ying time after hub disinfection.82For prevention of hub contamination, an antiseptic barrier cap was developed. This device optimizes needleless connector disinfection via cleaning of catheter hub, through keeping it in continuous contact with disinfectant.83,84co n c lu s I o nFor prevention of late CRBSI, along with other preventive interventions, disinfection of hub is an important step. Hence, it is widely advised to disinfect hub in contemporary guidelines and literature. Here also committe e decided to make recommendation for port utilization and maintenance.Recommendations• We recommend disinfecting hubs , needleless connectors, tap s, and injection por ts, before accessing catheter, with 70% alcohol or an alcoholic chlorhexidine preparation [A, 2].• We recommend wearing either clean or sterile gloves when handling the hub and catheter [A, 3].Prophylactic Antibiotics and AntisepticsEvidence StatementThe committee here in this section attempt to provide evidence based approach for infection prevention and maintenance. Extra-luminal [skin ora] source predominantly causes CRBSI during short-term [5–7 days] use of central venous catheters.85 -91 Thus, its logical that measures like maximizing skin antisepsis and preventing contamination during insertion remains the most important step to prevent CRBSI. Povidone-iodine or polysporin triple ointment applicatio n at HD catheter site [after insertion as well as after each dialysis] has been shown in m ultiple studies to prevent exit site infection an d CRBSI.92-95 Cochrane meta-analysis published in 2016 could nd very low qualit y data in support of skin antiseptics used for CVC catheter care, with chlorhexidine gluconate better than povidone-iodine. However, authors’ concluded that this low-quality evidence is insucient at the moment to recommend use of antiseptic solutions for routin e care of CVC site. Use of Mupirocin at local site is discouraged, as study documented high incidence of resistance among skin or a, especially staphylococci, in the unit after its routine use for this purpose.96 Caution advised with use of any ointment containing polyethylene glycol as base at catheter exit site, at its interacti on with catheter material is known to weaken the catheter, leading to spontaneous rupture of the catheter.97, 98Daily chlorhexidine b ath to decontaminate skin of ICU patients has been shown to reduce CRBSI and is strongly recommended Position Statement for Central Venous Catheterization and Management 2020Indian Journal of Crical Care Medicine, January 2020;24(Suppl 1)S16as cost-effective measure aimed at CRBSI prevention.9 9-10 4 Chlorhexidine soake d sponge or polyurethane dressing at inser tion site to prevent penetration of skin ora to CVC exit site has been proven to reduce catheter colonization and CRBSI.105 -111 Howeve r, use of sponge at exit site in patie nts treated with daily chlorhexidine bath in ICU as add on intervention is questioned.112Beyond second week the intraluminal microbiological source predominantly causes CRBSI. Contamination of catheter hub(s) is common source of colonization and subsequent intraluminal biolm formation. One study on intraluminal bacterial biolm formation showed up to 15% surface has biolm in less than ten days, but up to 40% surface if left in situ for 30 days.88 The incidence and incidence density of late-onset CRBSI in long-term oncology catheter s is 22.5% and 1.6/1,000 catheter days in tunneled vs. 3.6% and 0.1/1000 catheter days in totally implanted catheters [ports], pointing nger at ee ct of handling the catheter hub as a key risk factor for hub contamination. Improper handling of hubs and dicult to clean needleless p ort valves has been proven to increase CRBSI. Emerging evidence shows role of needle less connectors in reducing CRBSI rates. Antibiotic lock solutions, though eective in treating uncomplicated tunnele d long term CVC catheter CRBSI, are not recommended for p revention of CRBSI due to fear of emergence of antibiotic resistance with few exceptions.112- 117 In patients with long-term tunnele d catheters, who have limited venous access and repeated CRBSIs despite adequate preventive measures and are at high risk of sequela from CR BSI like recently implanted intravascular devices, such as prosthetic heart valve or aortic graft, pacemaker or AICD, antibiotic lock may be used as a CVC catheter salvage method. Here ade quate CRBSI prevention measures include at least three measures, namely education about CRBSI bundles to sta who insert and maintain CVC, use of maximal aseptic precautions during insertion and us e of 0.5% Chlorhexidine in alcohol solution for CVC site preparation.In absence of distant infec tion causing blood stream infection, seeding from blood stream is an uncommon mechanism of CRBSI. Antibiotics Injected systemically thus unlikely to have signicant concentration to alter skin or exit site ora [causing early CRBSI] or within the intraluminal or ex tra luminal biolm [causing late CRBSI] to have any eect in preventing CRBSI. This has been proven in multiple studies, that prophylactic antibiotics injected at the time of insertion or continued use during its use is unlikely to reduce CRBSI.118 -12 2 One Cochrane review showed low-quality evidence on use of prophylactic antibiotics in cancer patients with long-term implantable catheters , neutropenia post-chemotherapy with baseline CLABSI rate 15%.123 However, this evidence should not be extrapolated to routine ICU patients not having any of these high-risk conditions for whom prophylactic antibiotics if used will be ineective and pro mote antibiotic resistance in the unit.30 ,124 -126co n c lu s I o nDuring this evaluation of literature the commit tee was able to reach a consensus on many daily practice points, and recommendation made here in these sections can be bundled together for routine CVC care in many patient care settings.Recommendations• No recommendation can be made for or against the use of antiseptic solutions [Aqueous chlorhexidine or aqueous povidone-iodine] for routine CVC site care [A, 3].• We recommend the use of chlorhexidine soaked sponge or dressing at the catheter exit site to prevent CRBSI [A, 1].• We recommend daily chlorhexidine bed bath (sponging) for patients in ICU to reduce CRBSI incidence [A, 1].• We suggest use of antibiotic lock solutions to prevent CRBSI only in selected conditions as follows [B, 2]: – Limited or dicult venous access and a history of recurrent CRBSI – At high risk of severe sequela from a CLABSI (e.g., recently implanted intravascular devices, such as pacemaker or AICD, prosthetic heart valve, or aortic graft). – When CRBSI rate is high despite all measures to reduce it are implemented stringently.• We recommend against systemic intravenous antibiotics use for prevention of CRBSI [A, 1].Removal of Central line Evidence StatementCatheter colonization and intra- or extra-luminal biolm increases with each passing day.127,128 Thus CVC should be removes as soon as need ceases, however, routine change or relocating the central lines is not recommended. Removal of the central venous line also involves risks of air embolism, catheter fracture and embolism, dislodgement or thrombus or brin sheath hemorrhage, scars in addition to pain and discomfort during removal. Trendelenburg’s position, use of Valsalva maneuver, application of pressure at puncture site long enough to collapse the tract followed by application of occlusive dressing and monitoring the patient for complications for reasonable period is required after removal of central venous accesses. A CVC removal protocol and training is desirable.129co n c lu s I o nAlthough literature related to removal of central line protocol is scarce and mostly based upon expert opinion and low-quality observational studies, the committee unanimously agrees to recommendation present below, and considers them as useful practice points.Recommendations• We recommend removing central venous accesses as soon as its indication ceases [A, UPP].• We suggest not having policy to routinely replace relocate the central venous lines unless clinically indicated [B, UPP].• We recommend each institute to have central venous catheter removal protocol and only sta trained in the same to remove central venous accesses [A, UPP].Catheters Impregnated with Antiseptics and AntibioticsEvidence StatementFor preventing CRBSI, several dierent variations of antibiotic- and antiseptic-coated catheter have been marketed in previous years. These coatings include silver, platinum/silver, CHG-silver sulfadiazine of rst and second generation, minocycline/rifampicin. Silver- and platinum/silver-coated catheters have been studied in comparison noncoated catheters where equivocal results were produced for catheter colonization.130-13 4 Position Statement for Central Venous Catheterization and Management 2020Indian Journal of Crical Care Medicine, January 2020;24(Suppl 1) S17Chlorhexidine gluconate/silver sulfadiazine (C/SS) coated catheter were studies in many studies and analysis.135- 140 First generation of such CVCs had coating only on outer surface whereas second generation additionally had CHG inner coating extending till the hubs. Second generation devices have higher CHG concentration on outer surface. There are several RCTs and meta-analysis that shows superiority of second generation over rst generation and rst generation over noncoated CVC in terms to prevent colonization; however, these studies produ ced equivocal ndings for CRBSI.138-14 0Minocycline/rifampicin (M/R) impregnated catheters with coating on both sides, studied in comparison with rst generation C/SS-coated CVC, found to be having low colonization and CRBSI rates.141-143 The beneficial effect begins after 6 days of catheterization. In a recent before and after study comparing M/R and second generation C/SS catheter also found that M/R CVC signicantly reduced colonization and CLABSI rates.144 H ow ever, the study reported no signicant change in microbial prole and no increase in resistance pattern.144Gold salt preparations (Auranon) releasing CVC have been developed. It claims to be having antibacterial and antibiolm property.145 However, pending human trials these cannot be recommended at any point soon.co n c lu s I o nPlethora of literature suggests antibiotic/antimicrobial coated CVC reduces CRBSI rates, however, studies also suggest that maximal benet is seen after the sixth day and more so in a long-term CVC. Using these devices although seems lucrative in rst ush, but this comes with serious cost implications and apprehension of developing antibiotics resistance. Committee stresses on the fact that any novel approach cannot substitute for b asic infection control practices, hence recomm end use of antibiotic- or antiseptic-coated CVC only when CLABSI rates are not comparab le to benchmark even after successful implementation of such strategy.Recommendation• We recommend using M/R- or C/SS -coated CVCs when catheter is expected to be in use for more than 5 days and the CLABSI rate is not decreasing to the institutional target benchmark even after implementing comprehensive strategy program. Comprehensive strategy should include education and training, maximal barrier pre caution and aseptic skin preparation while insertion of CVC [A, 1].Pr e v e n t I o n o f M e c h A n I c A l co M P l I c At I o n sRole of SonographyEvidence StatementUS-guidance facilitates safe CVC placement.146 There are concrete evidences now, that USG oers advantage of safety and quality during IJV-C VC placement. However, for the SCV and femoral routes, the gain of safety and quality is very small.147A meta-analysis and s ystematic review by Lalu, et al. comparing US and landmark technique for SC V catheterization and concluded that USG-guided SCV catheterization reduced the frequency of adverse events compared with the landmark technique.148However, it might be technically dicult to prove benet of USG for CVC placement in the subclavian vein, because US-guided approach is technically mor e challenging. USG shows less benet for the femoral route as mechanical complications other than arterial puncture occur infrequ ently. Altered anatomy of femoral vein often demands USG guidance.The American Society of Echocardiography and the Society of Cardiovascular Anaesthesiologists in 2012149 strongly recommend ed real time US-guided CVC insertion, however, the level of evidence for SCV and femoral CVC insertion was not as strong as that of IJV.Similarly, the Association of Anaesthetists of Great Britain and Ireland also recommends US-guided CVC placement in IJV. This document recommends US -guided CVC placement for othe r sites as well but recognizes that evidence, at pres ent is limited for them.150co n c lu s I o nThe committee unanimously agrees that USG guidance improves procedural safety. The evidence for same is strong for IJV access and relatively low for SCV and femoral access. Although the technology needs further dissemination and many practitioners need to acquire the US skills. The committee also recognizes the fact that in a resource-limited setting where stringent legal issues exist in acquiring US technology, it is not prudent to recommend it for every clinical situatio n and for every type of healthcare se tup. Hence recommendation in favor of US use is rew ritten in accordance with our local medicolegal obligations.Recommendation• Wherever available we recommend US guidance to improve success rate, patient safety and procedural quality and reduce mechanical complications during CVC placement.[A, 2]Guidewire ExchangeEvidence StatementCVC can either be inserted \"de novo” or placed by guidewire exchange (GWE). In spite of availability of real-time US guidance, there are certain conditions where central vein patency is diminished in ICU patients. In those f ew selective conditions, it may be necessary to exchange CVC using a guidewire.151-155Shimada et al.156 described a technique for catheter exchange where an outer sheath is placed over an existing catheter, subsequently the sheath removed after placement of a new catheter.Whereas in guidewire exchange, a gui dewire is passed through the distal port of the CVC and old catheter is rem oved, while a new one is placed over the existing guidewire.157Cook et al. included 12 randomized control studies in their meta-analysis and assessed CVC management through routine replacement of CVC over guidewire. This analysis failed to demonstrate any reduce rate of CRBSI and routine re placement over a guidewire is not recommended at least in functioning catheters and have no evidence of causing local o r systemic complications.151 However, guidewire exchange is less discomforting and have signicantly low mechanical complications.153 Exchange over wire can be of use in limited venous access scenarios, with high success rates and very low mechanical complication rates but should not be done in conrm or clinical suspicion of BSI, as tract colonization is the usual source of BSI.69 ,153 Coagulopathy is also one of the conditions warrant guidewire exchange for CVC placement in critically ill patients. Position Statement for Central Venous Catheterization and Management 2020Indian Journal of Crical Care Medicine, January 2020;24(Suppl 1)S18The ELVIS trial, a multicenter, randomized, double blind trial, had 16 participating ICU units and enro lled 1460 critically- ill patients that needed dialysis catheter replacement. A guidewire exchange does not pose signicant risk f or CRBSI but predispose for catheter dysfunction . This dysfunction is inability to maint ain extracorporeal blood ow.158- 160co n c lu s I o nGuidewire exchange technique may be useful in many clinical scenarios, where chances of mechanical complication can be very high such as in emergent situations, unavailability of resources such as USG, expert personnel, etc. The evidences in present topic suggest exchange can be used in these limited settings, only if there is no evidence or suspicion of BSI.Recommendation• We suggest exchange of malfunc tioning CVC over guidewire in selected patients with no evidence of infection.[B, 2]Tip PositioningEvidence StatementPrimary central venous cathe ter (CVC) tip malposition is a common occurrence with incidence of around 6. 8%.161 However, much higher rates of catheter malposition, of up to 10–30%, have been rep orted when the CVCs are placed w ithout any radiological guidance.162-164Correct positioning of CVC tip is vital to prevent complications associated with CVC insertion. The most dreaded complication of CVC insertion is cardiac tamponade, which is associated with high mortality.165,166 The complication is more frequent in distally placed CVC tips and may occur secondary to perforation of the vein or the cardiac chamber. The other common complication of intra-atrial tip positioning is arrhythmias. Hence, the US Food and Drug Administration (FDA) has recommended that the CVC tip should not be placed in or allowed to migrate into the heart.167 On the other hand, CVC catheters, if placed more proximally in the superior vena cava (SVC), increase the risk of venous thrombosis, migration and malfunction.168,16 9It is prudent to check and document the tip position after C VC placement.170 Several methods have been tried to place the CVC tip in the correct positi on. These include clinician devised formulas like the Peres164 and Andropoulos,171 or the use of radiological techniques such as the chest X-ray (CXR), ultrasonography (USG), real-time uoroscopy or the right atrial (RA) electrocardiography (ECG) and transesophageal echocardiography (TEE). Newer methods such as proximity of cardiac motion method, have also been tried to ensure the correct placement.172 Several landmarks on a CXR have been suggested as an ideal site for positioning the CVC tip, like the site between the fth and sixth thoracic vertebrae173 and the site below the inferio r border of the clavicles.174 However, these anatomic landmarks are not in the same plane as the SVC and hence, on a CXR, it results in a parallax eect, leading to signicant errors in positioning of the CVC tip.162 Hence, an anatomical landmark, which is closer to the plane in which the SCV lies, has been suggested.163 Carina lies about 3 cm above the SVC/RA junc tion and can be easily identied in a CXR.175 Hence, CVC tips should be positioned above the carina, which can be considered as a ‘safe’ area.163To prevent endoluminal injury, and resultant thrombosis and perforation, th e course of the catheter should be parallel to the wall of the SVC and the tip of the catheter should m ove freely within the vascular lumen. Such a position is b est achieved when right internal jugular vein (IJV) is used for CVC insertion as the catheter runs a straight course into the lower SVC. Chances of th ese complications secondary to C VCs abutting the catheter wall are more with the lef t-sided catheters. As the CVCs inserted from the left side must turn a 90° corner to enter the SVC, if the CVC length is short, the distal tip may get positioned against the lateral wall of the SVC. Hence, positioning the tip of such cathe ters in the lower segment of the SVC may be preferred, where it tends to lie parallel to the vessel wall.164It is also essential to keep in mind that even after catheter placement; distal catheter tip may exhibit a range of movement, up to 2–3 cm, in majority of patients. This range of movement may depend upon several factors such as the site of insertion and the patient’s body habitus. The position of the CVC tip also varies with respiration and position of the patient. Because of this, it may commonly migrate into upper part of SVC, IJV, RA, right ventricle, subclavian or the innominate vein. Hence, the position of the CVC and its distal tip should be frequently monitored as long as the catheter is in situ. 176co n c lu s I o nTip positioning is vital to avoid many delayed mechanical complications of CVC. Post-procedure chest X-ray is considered a standard practice for tip positioning although other modalities can also be used for same purpose. The commit tee suggests chest X-ray for routine documentation and f or complication surveillance.Recommendations• We recommend post-procedure, position of the catheter tip must be assessed [A, UPP].• We recommend IJ and SCV catheter tip should be placed in the lower one third of the SVC near the SVC/RA junction [A, 2].• We recommend the use of chest X-ray to assess the CVC cathe ter tip position [A, 2].su r v e I l l A n c eInfection ControlEvidence StatementSurveillance of CVC-related infec tion control practices is important quality improvement strategy. In this section, the committee evaluated the literature and made its recommendation on various surveillance approaches. Checklist for insertion and maintenance phase of CVC was debated.Routine removalSeveral prospective obs ervational studies found that more the days of use of central venous catheter higher the incidence of positive catheter tip culture.177-18 0 Nonrandomized comparative studies indicate that durations of CVC use has a positive correlation with rates of catheter colonization, and inf ection. These observatio n lead to routine removal of central venous catheter to prevent central venous catheter-related bloodstream infection (CRBSI). However, randomized controlled trials reported e quivocal ndings regarding dierences in catheter tip colonizatio n when catheters are changed at three versus seven day intervals.181,182 One recent multi-centric study observed that early removal of CVC even in diagnosed CRBSI did not decrease mortality.183 A subgroup analysis of two Position Statement for Central Venous Catheterization and Management 2020Indian Journal of Crical Care Medicine, January 2020;24(Suppl 1) S19phase III, multicenter, double-blind, randomized, controlled trials examined the eects of early CVC removal (within 24 or 48 hours after treatment initiation) on the outcomes of 842 patients with candidemia. It found that early CVC removal was not associated with any clinical benet.184 Another s tudy of 78 patients with CRBSI caused by multidrug resistance antimicrobials reported increased mortality, if infected CVC was not removed.185Catheter tip cultureClinical ndings alone are not reliable method for diagnosing device-related infection and most of these clinical ndings are not enough sensitive or specic. Traditionally, culturing catheter tip has been advocated as a denite method to diagnose CRBSI.186 But practice of sending a tip culture is not used widely. Clinicians are mostly inuenced by CDC and NHSN surveillance denitions for CLBSI as it does not consider TC results.187 There is reported poor positive predictive value of catheter tip cultures in making diagnosis of CRBSIs188 further guidelines limit s tip culture sampling to high probability cases only thus may have decreased a practice of over-culturing of CVC tips.186The trend of sampling a catheter tip is declining and only used in research scenarios. Although a tip cu lture is advised for diagnosis of CRBSI, in one study many users did n ot even started appropriate therapy for CRBSI while culturing catheter tips. Moreover, positive tip cultures are dicult to be interpreted as a sou rce or outcome.189Daily checklist to prevent CRBSIIn a quasi-control study, a total of 444 central catheters corresponding to 390 patients were observed. It was possible to observe a 54.5% decrease in the rate of central catheter infection when compared with the control group with the help of various prevention strategies.190 Another multi-centric study observed decreased incidence of CRBSI from 3.9 per 1000catheterdays to 1.0 per 1000catheterdays with the help of educational program teaching of hand hygiene, standards of cathetercare, and preparation of intravenous drugs.191 A multimodal central line associated bloodstream infection (CLABSI) risk reduction strategy consisting of: 2% chlorhexidine in 70% alcohol solution for skin preparation before CVC insertion, standardized CVC insertion packs, CVC inser tion guidelines, and nursing education re garding CRBSI care signicantly reduced incidence rate ration of CRBSI. A systematic review and meta-analysis of 79 studies found that strict adheren ce to CRBSI prevention bundle reduced its in cidence signicantly from media n 6·4 per 1000 catheter-days (IQR 3·8 –10·9) to 2·5 per 1000 catheter-days (1·4–4·8) (IRR 0·44, 95% CI 0·39–0·50, p 0·0001;I2 = 89%).192co n c lu s I o nAfter evaluating the relevant liter ature for surveillance of infection control, the committee unanimously agrees to the fact that following a bundle of highly recommended practices makes use and maintenance of CVC safer. It was also able to determine the fact that long recommended practice of culturing and dening CVC-related infection also needs timely modication, and so is followed in recommendations made by the committee.Recommendations • We recommend against routine replacem ent of CVCs to prevent catheter-related infections [A, 1].• We recommend prompt removal of CVC when it is not ess ential [A, 2].• We recommend against routine catheter-tip cultures for purpose of surveillance [A, 2].• We recommend that routine practice bundle (Appendix II) should be followed to reduce CVC-related infections [A, 1].Surveillance of Mechanical ComplicationsEvidence StatementSurveillance for mechanical complication is necessary as these may cause immediate and delayed threat to life. Th ese mechanical complications are pneumothora x, hemothorax, malposition of C VC, arterial puncture and hematoma formation. Surveillance should be continued even, if CVC was tried but could not be secured.Till date, the post-procedural chest X-ray has been considered as the reference standard to detect mechanical complications. Some studies suggest that it should not be considered a reliable procedure for detecting complications in the absence of clinical symptoms. In addition, reading of a bedside CXR alone is not very accurate to identify intra-atrial tip position. The exceedingly low complication rate after right internal jugular vein catheterization suggests that, to detec t pneumothorax and intra-atrial malposition, routine post-procedure CXR is neither necessary nor accurate and causes delay until catheter use. Due to the developing knowledge and techniques in ultrasound, it can be suggested that it would be a suitable method to replace CXR in the rol e of detecting pneumothorax and identifying CVC tip position.PneumothoraxAblordeppey et al.193 in their systematic review and meta-analysis demonstrates that bedside ultrasound accurately identifies pneumothorax after CVC insertion. The sensitivity and specicity of ultrasound for identication of post-procedure pneumothorax was nearly 100% in most of the literature. Previo us literature to this systematic review also states that the sup eriority of ultrasound when compared to chest radiography for pneumothorax detection.194-198 A meta-analysis done by Alrajab et al,199 who reviewed 13 studies, demonstrated a p ooled sensitivity of 78.6% and specicit y of 98.4% for chest ultrasonography (CUS), while these rates were 39.8% and 99.3% for CXR, respectively.Recently a Prospective Ob servational Study (COMBUX-study)200 is in final phase of completion which is designed to compare bedside ultrasound with chest X-ray to detect CVC-related mechanical complications . This may likely to conrm the superiority of ultrasonography as a diagnos tic modality to standard chest X-ray to detect various mechanical complications.Thrombotic ComplicationsCentral venous catheterized patients are at high risk for catheter-related thrombosis. Used routinely, ultrasonography with color Doppler imaging could detects venous thrombosis in 33% of patients in medical ICU patie nts and in approximately 15% of these patients the thrombosis is catheter-related.201Arterial punctureIn a patient with normal blood pressure and normal arterial oxygen tension, arterial puncture is usually easy to identify by the pulsatile ow into the syringe and the bright-red color of the Position Statement for Central Venous Catheterization and Management 2020Indian Journal of Crical Care Medicine, January 2020;24(Suppl 1)S20blood. However, in patients with profound hyp otension or marked arterial desaturatio n, these ndings may not be present. If location of the catheter in the vein is uncertain, measuring intraluminal pressure, with a transducer prior to dilation aids in recognizing arterial puncture.HemothoraxPerforations of arteries or veins inside the chest can result in hemothorax, if the perforation communicates with the pleural space. While the mediastinum has relatively little potential space, the potential pleural space is up to approximately 3 liters, as the lung is completely compressible. Clearly, a catheter that per forates an artery or a vein , and also perforates and communicates with the pleural space rapidly can result in life-threatening hemorrhage. Diagnosis can begin with a simple ches t X-ray to locate the tip of the catheter. Injection of contrast into the catheter under uoroscopic examination also may be helpful in determining the location of the catheter.Catheter tip malposition/migrationAblordeppey et al.193 in their systematic review and meta-analysis stated that in CVC malpositionin g, bedside ultrasound will identify four out of every ve malpositioning. Importantly, ultrasound provides results regarding catheter position and pneumothorax faster than chest radiography. They recommend that bedside ultrasound be used as rs t-line conrmation metho d to determine catheter malposition. If the CVC is found to be mal-positioned in a venous structure, the CVC can be expediently addressed without obtaining a chest radiogra ph rst. However, if the CVC malposition is not detected by ultrasound and concern is high for malposition, such as in the case of multiple cannulatio n attempts or incomplete/inadequate ultrasound conrmation technique, chest radiography should be performed to rule out catheter malposition. After review and analysis of the cu rrent literature, best practice for ultrasound-guided conrmation of CVC positioning includes a focused vascular and cardiac ultrasound with rapid non-agitated saline ush. co n c lu s I o nGiven the relative benets of ultrasound with respect to image feasibility and ecien cy, this modality ne eds further dissemination and implementation into clinical practice. USG guidance for surveillance of complication needs learning curve and is very subjective and operator dependent. In present scenarios, the committee abstains from recommending USG for routine use of post-procedure surveillance.Recommendations• We recommend chest X-ray post-inser tion of IJ AND SC central line [A, 2].• We suggest that ultrasound guidance can be used for early identication of mechanical complication [B, 2].Education, Training, CQI initiatives and Audit Evidence Statement: Education and Training The committee whil e drafting this document felt strongly that C VC care cannot be improved if an education and training CQI initiative is not implemented.It is essential to have well-organized training program for overall process and outcome improvement. Ample amount of data accumulated in past several decades that suggest that risk of colonization and infection reduces with standardized aseptic care.202-208 Data also suggest that rate of infectious and other complication increases with untutored persons handling the CVC..205,209 Proper stang level and care also suggested being an important factor in overall quality of CVC care.210 -221 Stang with regular critical care nurs es and reduced pool nurses improves CVC-related outcomes.222,223co n c lu s I o n The committee unanimo usly agrees to the fact that education and training on best prac tices for healthcare professionals is imperative for overall quality improvement. Committee nds it prudent to guide about appropriate stang pattern and level of training.Recommendations• We recommend that a healthcare education and training program should be in place wherever CVCs are inserted and maintained for overall quality improvement [A, 1].• We recommend that a mechanism should be in p lace to assess knowledge and compliance w ith guidelines of all the personnel involved in care related to CVC [A, 1].• We suggest maintaining appropriate and adequate nursing level at all times to improve CVC-related outcomes [B, 2].Evidence Statement: CQI InitiativesIn our country where CVC care practices are heterogeneous, the committee decided to revalidate and roll out the standards of CQI to help practitioner maintain a uniform practice. Also committee prescribed some m easures to audit the process and outcome. Audit for infectious complic ations as a result of central venous cannulation should be a routine in any organizati on to prevent or at least reduce the rate of these complications.Formulating and implementing a uniform evidence-based practice is high priorit y. However data suggest that CRBSI preventive strategy adherence in American hospitals is suboptimal.224,225 Even use of universally recommended strategy like hand washing, maximal barrier precaution and CHG skin preparation is suboptimal.30,226 Large amount of data in form of quality improvement studies has been published in past few years, which include research on various strategies such as education training, stang, feedback program, organizational change.22 7-236 Several before and after studies and controlled trials for educational programs and training (e.g. training for maximal barrie r precaution, site selection, line-care protocol, prompt removal strategy, etc.) reported signicant improvement in CRBSI outcomes.205,232,237 Bundling multiple evidence-based approaches was also tested in many studies and had statisticall y signicant improvement in CRBSI outcomes with an ease of implement ation.205,231,232,238 This \"bundle and checklist” approach for preparation, insertion, maintenance and removal also provides opportunity to improve performance, both at individual and unit ’s level and help in quality improvement.Recommendation• We recommend using institutional CQI initiatives with bundled approach for performance improvement [A, 2]. Position Statement for Central Venous Catheterization and Management 2020Indian Journal of Crical Care Medicine, January 2020;24(Suppl 1) S21Evidence Statement: Audit ToolsTools to detect CLABSIFor the purpose of standardization universally accepted National Healthcare Safety Network (NHSN), CDC definitions for BSI surveillance are used in this document and provided here in Appendix III.4 The committee recommends continuous audit and surveillance with these denitions to allow comparison with benchmark.1Tools for performance measuresStandard tools for performance measures are accepted and adopted here in this document also for benchmarking and uniformity purpose. The internal reporting requirement tools are presented in, strategies to prevent central line associated blood stream infections in acute care hospitals-2014 update. 33Internal reporting is used to support internal CQI initiatives. These process and outcomes measures are derived from other contemporary literature and guidelines. These measures should be reported to internal stake holders such as clinicians, hospital quality administration and nursing leadership.Recommendations• We recommend conducting surveillance to determine CLABSI rates, monitor its trends and identif y lapses in Infection Control Practices [A, 1].• We do not recommended routine culture of catheter tip for purpose of surveillance [A, 1].• DTTP is the recomme nded method of diagnosis for CVC-related infections in patients [A, 2].• We suggest recording the operator, date and time of catheter insertion and removal and dressing changes on a standardized form [A, UPP].Consents and Medicolegal IssuesEvidence Statement As with any other procedure in medical practice, CVC also have serious medicolegal implications. This section does not need any recommendation as these are governed by the law of the land of India, and absolute compliance to these laws is the only recommendation the committee could make.Vicarious liabilityPerson who has been trained and qualied to perform central venous pressure would be responsible for procedure-related consequences. Trainee/nursing staff/technician-performing procedure must perform under supervision of trained person and he/she would be accountable under vicarious liability.Contents of consent• ‘Informed consent’ is mandatory.• Consent form must be lled by the doctor (one who either performs procedure himself or is a part of team who performs procedure), in one sitting, preferably without changing pen• Consent must be carried out in a manner and language the patient/proxy can understand.• Patient name and his identication numb er must be mentioned clearly• Consent must not be clubbed with consents for procedure(s) other than Central venous catheter insertion• Consent must mention medically recognized alternative measures relating to diagnosis or treatment, including measures that may be considered less desir able by the physician• Consent should include consequen ces of the patient’s/proxy ’s decision to decline or refuse treatment • Consent must be taken from patient, however if patient in not capable to give consent it can be taken from proxy with mentioning of valid reason(s) for incapacity of patient to consent.CredentialingTo limit the disparity and haphazard practice, and purpose of standardization it is mandatory that every institution has a policy and credentialing process. These can be exible according to local needs, but absolute comp liance to medicolegal issues and standard practice in accordance with this document an d local medical council guidelines is suggested. Recommendation• We suggest that a structured credentialing process be in place for personnel involved in insertion and maintenance of CVC [B, UPP]. Position Statement for Central Venous Catheterization and Management 2020Indian Journal of Crical Care Medicine, January 2020;24(Suppl 1)S22AP P e n d I x IIRoutine Practice BundleStrict adherence to following practices to prevent catheter-related bloodstream infection (CRBSI) should be implemented for routine care and maintenance:• Comply with hand hygiene requirements. • Bathe ICU patients with a chlorhexidine preparation on a daily basis.• Scrub the access port or hub with friction for 10 seconds, immediately prior to each use with an appropriate antiseptic (chlorhexidine, povidone iodine, an iodophor, or 70% alcohol). • Use only sterile devices to access catheters. • Immediately replace dressings that are wet, s oiled, or dislodged. • Perform routine dressin g changes using aseptic technique with clean or sterile gloves. – Change gauze dressings at least every 2 days or semipermeable dressings at least every 7 days. • Change administrations sets for continuous infusions no more frequently than every 4 days, but at least every 7 days. – If blood or blood p roducts or fat emulsions are administered change tubing every 24 hours. – If p ropofol is administered, change tubing ever y 6–12 hours or when the vial is changed.• Promptly remove unnecessar y central lines. Perform daily audits to assess whether each central line is still needed.AP P e n d I x IIICDC and NHSN Surveillance DenitionsPrimary bloodstream infection (BSI): A laboratory-confirmed bloodstream infection (LCBI) that is not secondary to a bacterial infection at another body site.Secondary BSI: A BSI that is thought to be seeded from a site-spe cic infection at another body site.Eligible BSI organism: Any organism that is eligible for use to meet LCBI or mucosal barrier injury laboratory-conrmed bloodstream infection (MBI-LCBI) criteria.Catheter-related bloodstream infection (CRBSI): CRBSI attributed to an intravascular catheter by quantitative culture of the catheter tip or by dierences in growth between catheter and peripheral venipuncture specimens. This definition is primarily used in research.Central line-associated BSI (CLABSI): It is an LCBI where an eligible BSI organism is identied and an eligib le central line (CL) in a patient is present within 48 hours p eriod before the development of the BSI, and that is not related to an infection at another site. Position Statement for Central Venous Catheterization and Management 2020Indian Journal of Crical Care Medicine, January 2020;24(Suppl 1) S23The case denition for the diagnosis of CLABSI (LCBI) as per CDC is as following (must meet one of the three criteria).• LCB I -1: Patient has recognized pathogen cultured from one or more blood cultures and Organism cultured from blood is not related to infection at another site.• LCBI-2: Patient has at least one of the following signs and symptoms: Fever ( 38°C), chills, or hypotension, and• Signs and symptoms and positive laboratory ndings are not related to infection at other site, and• Common skin contaminants are cultured from two or more blood cultures drawn on separate occasions.• LCBI-3: Patient of age less than or equal to 1 year has at least one of the following signs and symptoms: Fever ( 38°C) core, hypothermia ( 36°C) core temperature, apnea, or bradycardia, and Signs and symptoms and positive laboratory ndings are not related to infection at other site, and Common skin contaminants are cultured from two or more blood cultures drawn on separate occasions.Central LineIt is an intravascular access device or catheter that terminates at or close to the heart, or in one of the great vessels. • The line may be used for infusio n or hemodynamic monitoring and may be inserted centrally or peripherally (PICC line). • Once a line has been designated a CL it continues to be a CL, regardless of migration (Migrated CL), until removed from the body or patient is discharged, whichever is earlier.• A non-lumened intravascular catheter that terminates at or close to the heart or in a great vessel which is not used for infusion, withdrawal of blood or hemodynamic monitoring is not considered a CL.• Eligible CL: The one that has been in place for more than two consecutive days (on or after CL day 3), following the rst access of the central line, in an inpatient location, during the current admission. Such lines are eligible for CLABSI events.• Central line days: The number of days a CL has been accessed to determine if LCBI is a CLABSI.• Denominator count days: The count of CL on an inpatient unit that is recorded in the monthly denominator summary data.Types of central linesThere are following three types of CL for CLABSI surveillance.1. Permanent CL: It includes— • Tunneled catheters including tunneled dialysis catheters • Implanted catheters including ports.2. Temporary CL: These are non-tunneled and non-implanted catheter.3. Umbil ical catheter: Th ese are vascular catheter inserted through the umbilical arter y or vein in a neonate. All umbilical catheters are considered as CL.Access: It is dened as entering the CL with a needle or needleless device for infusion, withdrawal of blood, or hemodynamic monitoring.• The day of insertion is considered as day of access and hence, counted as rst central line day.• If an outpatient patient comes with a CL already in place and it is the only CL in body, then the rst day access in inpatient location begins the central line day count (CL day 1).De-accessing any type of CL, e.g. removing the port needle but port remains in the body, simply does not remove the patient from CLABSI surveillance.Ac k n o w l e d g M e n t sDr Simant Jha, Dr Rohit Yadav, Dr Prasad Padwal, Dr Ashima Katyal, Dr Prajkta Wankhedereferences 1. National healthcare safety network (NHSN) patient safety component manual. Jan’2020. Accessed from, https://www.cdc.gov/nhsn/pdfs/pcsmanual current.pdf 2. Nancy Moureau, Vineet Chopra. 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Position Statement for Central Venous Catheterization and Management 2020Indian Journal of Crical Care Medicine, January 2020;24(Suppl 1)S301Department of Critical Care, Anesthesia and Emergency Medicine, Regency Health, Lucknow, Uttar Pradesh, India, Phone: 91-9818716943, e-mail: dryashjaveri@yahoo.com2Department of Critical Care Medicine, Medicover Hospital, Hyderabad, Telangana, India, e-mail: drganshyam@gmail.com 3Department of Critical Care Medicine, Sanjeevan MJM Hospital, Pune, Maharashtra, India, e-mail: subhaldixit@gmail.com4Department of Pulmonary and Critical Care, Pandit Bhagwat Dayal Sharma Post Graduate Institute of Medical Sciences, Rohtak, Haryana, India, Phone: 9991101616, e-mail: dhruvachaudhary@yahoo.co.in5Department of Neuro Trauma Unit, Grant Medical Foundation, Pune, Maharashtra, India, Phone: 9822844212, e-mail: kapilzirpe@gmail.com6Department of Critical Care and Anesthesiology, Medanta The Medicity, Sector-38, Gurgaon, Haryana, India, Phone: + 91 124 4141414 Extn. 3335, e-mail: yatinmehta@hotmail.com7Department of Critical Care, Medanta Hospital, The Medicity, Gurugram, Haryana, India, Phone: 91-11-26692531, e-mail: drdeepak_govil@yahoo.co.in8Department of Critical Care, Saneejivini Hospital, Vastrapur, Ahmedabad, Gujarat, India, Phone: +91-9924231500, e-mail: mishr.c@gmail.com9Department of Critical Care, Virinchi Hospital, Hyderabad, Telangana, India, Phone: 9866343632, e-mail: srinivas3271@gmail.com 10Department of Intensive Care Unit, Fortis Hospital, Mumbai, Maharashtra, India, Phone: 91-22-25216332, e-mail: dr_rapandit@yahoo.com11Department of Critical Care Medicine, Apollo Hospital, Chennai, Tamil Nadu, India, e-mail: raymond.savio@gmail.com 12Department of Intensive Care, Services Sunshine Global Hospital, Surat, Gujarat, India, e-mail: anujmclerk@hotmail.com13Department of Critical Care Medicine, Manipal Hospital, New Delhi, India, Phone: 91-0124-4030723, e-mail: srinivasan.shrikanth@gmail.com 14Department of Critical Care Medicine, Max Superspecialty Hospital, New Delhi, India, Phone: 91-011-22505894, e-mail: devenjuneja@gmail.com15Department of Critical Care, Artemis Hospital, Gurugram, Haryana, India, e-mail: drsray67@Yahoo.co.in 16Department of Critical Care, Medanta Hospital, Ranchi, Jharkhand, India, Phone: 91-011-42252404, e-mail: tapask.sahoo@gmail.com17 Department of Critical Care Medicine, Citizens Specialty Hospital, Hyderabad, Telangana, India, Phone: 9652342973, e-mail: sjakkina@gmail.com 18Department of Critical Care, Medicover Hospital, Hyderabad, Telangana, India, Phone: 9948454299, e-mail: dr.nandhakishore23@gmail.com19Department of Critical Care Medicine, Nayati Medicity, Mathura, Uttar Pradesh, India, Phone: 8375075415, e-mail: ravijainstar@gmail.comCitations (0)References (217)ResearchGate has not been able to resolve any citations for this publication.Effectiveness of different central venous catheter fixation suture techniques: An in vitro crossover studyArticleFull-text availableSep 2019PLOS ONE Manuel F StruckLars Friedrich Stefan Schleifenbaum Bernd E WinklerPURPOSE:Proper fixation of central venous catheters (CVCs) is an integral part of safety to avoid dislodgement and malfunction. However, the effectiveness of different CVC securement sutures is unknown.METHODS:Analysis of maximum dislodgement forces for CVCs from three different manufacturers using four different suture techniques in an in vitro tensile loading experiment: 1. clamp only , 2. clamp and compression suture , 3. finger trap and 4. complete , i.e., clamp + compression suture + finger trap . Twenty-five tests were performed for each of the three CVC models and four securement suture techniques (n = 300 test runs).RESULTS:The primary cause of catheter dislodgement was sliding through the clamp in techniques 1 and 2. In contrast, rupture of the suture was the predominant cause for dislodgement in techniques 2 and 3. Median (IQR 25-75%) dislodgement forces were 26.0 (16.6) N in technique 1, 26.5 (18.8) N in technique 2, 76.7 (18.7) N in technique 3, and 84.8 (11.8) N in technique 4. Post-hoc analysis demonstrated significant differences (P .001) between all pairwise combinations of techniques except technique 1 vs. 2 (P = .98).CONCLUSIONS: Finger trap fixation at the segmentation site considerably increases forces required for dislodgement compared to clamp-based approaches.ViewShow abstractThe impact of chlorhexidine bathing on hospital-acquired bloodstream infections: A systematic review and meta-analysisArticleFull-text availableMay 2019BMC INFECT DIS Jackson S MusuuzaPramod K. Guru John C O Horo Nasia SafdarBackgroundChlorhexidine gluconate (CHG) bathing of hospitalized patients may have benefit in reducing hospital-acquired bloodstream infections (HABSIs). However, the magnitude of effect, implementation fidelity, and patient-centered outcomes are unclear. In this meta-analysis, we examined the effect of CHG bathing on prevention of HABSIs and assessed fidelity to implementation of this behavioral intervention.MethodsWe undertook a meta-analysis by searching Medline, EMBASE, CINAHL, Scopus, and Cochrane’s CENTRAL registry from database inception through January 4, 2019 without language restrictions. We included randomized controlled trials, cluster randomized trials and quasi-experimental studies that evaluated the effect of CHG bathing versus a non-CHG comparator for prevention of HABSIs in any adult healthcare setting. Studies of pediatric patients, of pre-surgical CHG use, or without a non-CHG comparison arm were excluded. Outcomes of this study were HABSIs, patient-centered outcomes, such as patient comfort during the bath, and implementation fidelity assessed through five elements: adherence, exposure or dose, quality of the delivery, participant responsiveness, and program differentiation. Three authors independently extracted data and assessed study quality; a random-effects model was used.ResultsWe included 26 studies with 861,546 patient-days and 5259 HABSIs. CHG bathing markedly reduced the risk of HABSIs (IRR = 0.59, 95% confidence interval [CI]: 0.52–0.68). The effect of CHG bathing was consistent within subgroups: randomized (0.67, 95% CI: 0.53–0.85) vs. non-randomized studies (0.54, 95% CI: 0.44–0.65), bundled (0.66, 95% CI: 0.62–0.70) vs. non-bundled interventions (0.51, 95% CI: 0.39–0.68), CHG impregnated wipes (0.63, 95% CI: 0.55–0.73) vs. CHG solution (0.41, 95% CI: 0.26–0.64), and intensive care unit (ICU) (0.58, 95% CI: 0.49–0.68) vs. non-ICU settings (0.56, 95% CI: 0.38–0.83). Only three studies reported all five measures of fidelity, and ten studies did not report any patient-centered outcomes.ConclusionsPatient bathing with CHG significantly reduced the incidence of HABSIs in both ICU and non-ICU settings. Many studies did not report fidelity to the intervention or patient-centered outcomes. For sustainability and replicability essential for effective implementation, fidelity assessment that goes beyond whether a patient received an intervention or not should be standard practice particularly for complex behavioral interventions such as CHG bathing.Trial registrationStudy registration with PROSPERO CRD42015032523.Electronic supplementary materialThe online version of this article (10.1186/s12879-019-4002-7) contains supplementary material, which is available to authorized users.ViewShow abstractA clinical evaluation of two central venous catheter stabilization systemsArticleFull-text availableDec 2019 Tarja KarpanenAnna L. Casey Tony WhitehouseTom S. J. ElliottBackgroundCentral venous catheters (CVCs) are commonly secured with sutures which are associated with microbial colonization and infection. We report a comparison of a suture-free system with standard sutures for securing short-term CVC in an international multicentre, prospective, randomized, non-blinded, observational feasibility study. Consented critical care patients who had a CVC inserted as part of their clinical management were randomized to receive either sutures or the suture-free system to secure their CVC. The main outcome measures were CVC migration (daily measurement of catheter movement) and unplanned catheter removals.ResultsThe per cent of unplanned CVC removal in the two study groups was 2% (suture group 2 out of 86 patients) and 6% (suture-free group 5 out of 85 patients). Both securement methods were well tolerated in terms of skin irritation. The time and ease of application and removal of either securement systems were not rated significantly different. There was also no significant difference in CVC migration between the two securement systems in exploratory univariate and multivariate analyses. Overall, 42% (36 out of 86) of the CVC secured with sutures and 56% (48 out of 85) of the CVC secured with the suture-free securement system had CVC migration of ≥ 2 mm.ConclusionsThe two securement systems performed similarly in terms of CVC migration and unplanned removal of CVC; however, the feasibility study was not powered to detect statistically significant differences in these two parameters.Trial registrationISRCTN, ISRCTN13939744. Registered 9 July 2015, http://www.isrctn.com/ISRCTN13939744.ViewShow abstractBedside ultrasound to detect central venous catheter misplacement and associated iatrogenic complications: A systematic review and meta-analysisArticleFull-text availableDec 2018Crit Care Jasper Smit Reinder Raadsen Michiel J Blans Pieter R TuinmanBackground: Insertion of a central venous catheter (CVC) is common practice in critical care medicine. Complications arising from CVC placement are mostly due to a pneumothorax or malposition. Correct position is currently confirmed by chest x-ray, while ultrasonography might be a more suitable option. We performed a meta-analysis of the available studies with the primary aim of synthesizing information regarding detection of CVC-related complications and misplacement using ultrasound (US).Methods: This is a systematic review and meta-analysis registered at PROSPERO (CRD42016050698). PubMed, EMBASE, the Cochrane Database of Systematic Reviews, and the Cochrane Central Register of Controlled Trials were searched. Articles which reported the diagnostic accuracy of US in detecting the position of CVCs and the mechanical complications associated with insertion were included. Primary outcomes were specificity and sensitivity of US. Secondary outcomes included prevalence of malposition and pneumothorax, feasibility of US examination, and time to perform and interpret both US and chest x-ray. A qualitative assessment was performed using the QUADAS-2 tool.Results: We included 25 studies with a total of 2548 patients and 2602 CVC placements. Analysis yielded a pooled specificity of 98.9 (95% confidence interval (CI): 97.8-99.5) and sensitivity of 68.2 (95% CI: 54.4-79.4). US examination was feasible in 96.8% of the cases. The prevalence of CVC malposition and pneumothorax was 6.8% and 1.1%, respectively. The mean time for US performance was 2.83 min (95% CI: 2.77-2.89 min) min, while chest x-ray performance took 34.7 min (95% CI: 32.6-36.7 min). US was feasible in 97%. Further analyses were performed by defining subgroups based on the different utilized US protocols and on intra-atrial and extra-atrial misplacement. Vascular US combined with transthoracic echocardiography was most accurate.Conclusions: US is an accurate and feasible diagnostic modality to detect CVC malposition and iatrogenic pneumothorax. Advantages of US over chest x-ray are that it can be performed faster and does not subject patients to radiation. Vascular US combined with transthoracic echocardiography is advised. However, the results need to be interpreted with caution since included studies were often underpowered and had methodological limitations. A large multicenter study investigating optimal US protocol, among other things, is needed.ViewShow abstractComparison of the efficacy of three topical antiseptic solutions for the prevention of catheter colonization: A multicenter randomized controlled studyArticleFull-text availableDec 2017Crit Care Hideto YasudaMasamitsu SanuiTakayuki AbeAlan Kawarai LeforBackgroundTo compare the efficacy of three antiseptic solutions [0.5%, and 1.0% alcohol/chlorhexidine gluconate (CHG), and 10% aqueous povidone-iodine (PVI)] for the prevention of intravascular catheter colonization, we conducted a randomized controlled trial in patients from 16 intensive care units in Japan. MethodsAdult patients undergoing central venous or arterial catheter insertions were randomized to have one of three antiseptic solutions applied during catheter insertion and dressing changes. The primary endpoint was the incidence of catheter colonization, and the secondary endpoint was the incidence of catheter-related bloodstream infections (CRBSI). ResultsOf 1132 catheters randomized, 796 (70%) were included in the full analysis set. Catheter-tip colonization incidence was 3.7, 3.9, and 10.5 events per 1000 catheter-days in 0.5% CHG, 1% CHG, and PVI groups, respectively (p = 0.03). Pairwise comparisons of catheter colonization between groups showed a significantly higher catheter colonization risk in the PVI group (0.5% CHG vs. PVI: hazard ratio, HR 0.33 [95% confidence interval, CI 0.12–0.95], p = 0.04; 1.0% CHG vs. PVI: HR 0.35 [95% CI 0.13–0.93], p = 0.04). Sensitivity analyses including all patients by multiple imputations showed consistent quantitative conclusions (0.5% CHG vs. PVI: HR 0.34, p = 0.03; 1.0% CHG vs. PVI: HR 0.35, p = 0.04). No significant differences were observed in the incidence of CRBSI between groups. ConclusionsBoth 0.5% and 1.0% alcohol CHG are superior to 10% aqueous PVI for the prevention of intravascular catheter colonization. Trial registrationJapanese Primary Registries Network; No.: UMIN000008725 Registered on 1 September 2012ViewShow abstractDwindling Utilization of Central Venous Catheter Tip Cultures: An Analysis of Sampling Trends and Clinical Utility at 128 US Hospitals, 2009–2014ArticleJun 2019CLIN INFECT DIS Jennifer AdjemianYi Ling Lai Sameer S Kadri Emily E RicottaAt 128 US hospitals, from 2009–2014, a 17% decline occurred annually in central venous catheter tips sent for culture: a 6-fold decrease from blood culture sampling trends. The positive predictive value was low (23%). Tip culture use often does not conform to recommendations and offers limited independent treatment opportunities.ViewShow abstractEvaluation of Skin Colonisation And Placement of vascular access device Exit sites (ESCAPE Study)ArticleNov 2018 Nancy L Moureau Nicole Marsh Li Zhang Claire M RickardBackground: Skin microorganisms may contribute to the development of vascular access device (VAD) infections. Baseline skin microorganism type and quantity vary between body sites, yet there is little evidence to inform choice of VAD site selection.Objective: To compare microorganisms present at different body sites used for VAD insertions and understand the effect of transparent dressings on skin microflora.Methods: The ESCAPE observational study consisted of three phases: (1) skin swabs of four sites (mid-neck, base neck, chest, upper arm) from 48 hospital patients; (2) skin swabs of five body sites (mid-neck, base neck, chest, upper arm, lower arm) from 10 healthy volunteers; and (3) paired skin swabs (n = 72) under and outside of transparent dressings from 36 hospital patients (16 mid/base neck, 10 chest, upper arm). Specimens were cultured for 72 h, species identified and colony-forming units (CFU) counted. Ordinal logistic regression compared CFU categories between variables of interest.Results: The chest and upper arm were significantly associated with fewer microorganisms compared to neck or forearm (odds ratio [OR] = 0.40, 95% confidence interval [CI] = 0.25-0.65, P 0.05). CFU levels under transparent dressings were not significantly different from outside (OR = 0.57, 95% CI = 0.22-1.45). Staphylococci were predominant at all sites. Other significant (P 0.05) predictors of higher CFU count included prolonged hospitalisation and medical/surgical patient status.Discussion: Skin microorganism load was significantly lower at the upper arm or chest, compared to the mid- or base neck. This may impact VAD site selection and subsequent infection risk.ViewShow abstractComparative study on fixation of central venous catheter by suture versus adhesive deviceArticleAug 2018C.S. Molina-MazónX. Martín-CerezoG. Domene-Nieves de la Vega Jordi AdamuzObjectivesTo assess the efficacy of a central venous catheter adhesive fixation device (CVC) to prevent associated complications. To establish the need for dressing changes, number of days’ catheterization and reasons for catheter removal in both study groups. To assess the degree of satisfaction of personnel with the adhesive system.MethodA, randomised, prospective and open pilot study, of parallel groups, with comparative evaluation between CVC fixation with suture and with an adhesive safety system. The study was performed in the Coronary Unit of the Universitari de Bellvitge Hospital, between April and November 2016. The population studied were patients with a CVC. The results were analysed using SPSS Statistics software. The study was approved by the Clinical Research Ethics Committee.Results100 patients (47 adhesive system and 53 suture) were analysed. Both groups were homogeneous in terms of demographic variables, anticoagulation and days of catheterization. The frequency of complications in the adhesive system group was 21.3%, while in the suture group it was 47.2% (p = .01). The suture group had a higher frequency of local signs of infection (p = .006), catheter displacement (p = .005), and catheter-associated bacteraemia (p = .05). The use of adhesive fixation was associated with a lower requirement for dressing changes due to bleeding (p = .006). Ninety-six point seven percent of the staff recommended using the adhesive safety system.ConclusionsThe catheters fixed with adhesive systems had fewer infectious complications and less displacement.ViewShow abstractA Controlled Trial of Scheduled Replacement of Central Venous and Pulmonary-Artery CathetersArticleApr 1993Surv AnesthesiolDavid K. CobbK. P. HIGHR. G. SAWYERBarry M. FarrViewClinical impact of delayed catheter removal for patients with central-venous-catheter-related Gram-negative bacteraemiaArticleJan 2018J HOSP INFECTYu-Mi Lee Chisook MoonYoung Jin Kim Ki-Ho ParkBackground: Gram-negative bacteria are increasingly the cause of catheter-related bloodstream infections (CRBSI), which show a rapidly rising prevalence of multidrug-resistant strains. We evaluated the impact of delayed central venous catheter (CVC) removal on clinical outcomes in patients with gram-negative CRBSI.Methods: Between January 2007 and December 2016, patients with gram-negative bacteremia and CVC placement, from two tertiary care hospitals, were retrospectively included. Cases with CVC removal 3 days after onset of bacteremia or without CVC removal were classified as having delayed CVC removal.Results: A total of 112 patients were included. Of these, 78 had CRBSI (43 definite and 35 probable), and 34 had gram-negative bacteremia from another source (non-CRBSI). The Enterobacteriaceae were less frequent pathogens in patients with CRBSI than in those with non-CRBSI (11.5% vs. 41.3%; P 0.001). Delayed CVC removal was associated with increased 30-day mortality (40.5% vs. 11.8%; P = 0.01) in patients with gram-negative CRBSI; this was not seen in patients with non-CRBSI (25.0% vs. 14.3%; P 0.99). Delayed CVC removal [OR = 6.8], multidrug-resistant (MDR) gram-negative bacteremia [OR = 6.3], and chronic renal failure [OR = 11.1] were associated with 30-day mortality in patients with CRBSI. The protective effect of early CVC removal on mortality was evident in the MDR group (48.3% vs. 18.2%; P = 0.03), but not in the non-MDR group (11.1% vs. 0%; P = 0.43).Conclusion: CVCs should be removed early to improve clinical outcomes in patients with gram-negative CRBSI, especially where there is high prevalence of MDR isolates.ViewShow abstractShow moreAdvertisementRecommendationsDiscover moreProjectSepsis Biomarkers Dimple Anand Sumit Ray Lalit Mohan Srivastava[...] Saurabh TanejaView projectArticleFull-text availableIndian Society of Critical Care Medicine Position Statement for Central Venous Catheterization and M...January 2020 · Indian Journal of Critical Care Medicine Yatin Mehta Deepak GovilShrikanth Srinivasan[...] Ravi JainBackground and purpose: Short-term central venous catheterization (CVC) is one of the commonly used invasive interventions in ICU and other patient-care areas. Practice and management of CVC is not standardized, varies widely, and need appropriate guidance. Purpose of this document is to provide a comprehensive, evidence-based and up-to-date, one document source for practice and management of ... [Show full abstract] central venous catheterization. These recommendations are intended to be used by critical care physicians and allied professionals involved in care of patients with central venous lines.Methods: This position statement for central venous catheterization is framed by expert committee members under the aegis of Indian Society of Critical Care Medicine (ISCCM). Experts group exchanged and reviewed the relevant literature. During the final meeting of the experts held at the ISCCM Head Office, a consensus on all the topics was made and the recommendations for final document draft were prepared. The final document was reviewed and accepted by all expert committee members and after a process of peer-review this document is finally accepted as an official ISCCM position paper.Modified grade system was utilized to classify the quality of evidence and the strength of recommendations. The draft document thus formulated was reviewed by all committee members; further comments and suggestions were incorporated after discussion, and a final document was prepared.Results: This document makes recommendations about various aspects of resource preparation, infection control, prevention of mechanical complication and surveillance related to short-term central venous catheterization. This document also provides four appendices for ready reference and use at institutional level.Conclusion: In this document, committee is able to make 54 different recommendations for various aspects of care, out of which 40 are strong and 14 weak recommendations. Among all of them, 42 recommendations are backed by any level of evidence, however due to paucity of data on 12 clinical questions, a consensus was reached by working committee and practice recommendations given on these topics are based on vast clinical experience of the members of this committee, which makes a useful practice point. Committee recognizes the fact that in event of new emerging evidences this document will require update, and that shall be provided in due time.Abbreviations list: ABHR: Alcohol-based hand rub; AICD: Automated implantable cardioverter defibrillator; BSI: Blood stream infection; C/SS: CHG/silver sulfadiazine; Cath Lab: Catheterization laboratory (Cardiac Cath Lab); CDC: Centers for Disease Control and Prevention; CFU: Colony forming unit; CHG: Chlorhexidine gluconate; CL: Central line; COMBUX: Comparison of Bedside Ultrasound with Chest X-ray (COMBUX study); CQI: Continuous quality improvement; CRBSI: Catheter-related blood stream infection; CUS: Chest ultrasonography; CVC: Central Venous Catheter; CXR: Chest X-ray; DTTP: Differential time to positivity; DVT: Deep venous thrombosis; ECG: Electrocardiography; ELVIS: Ethanol lock and risk of hemodialysis catheter infection in critically ill patients; ER: Emergency room; FDA: Food and Drug Administration; FV: Femoral vein; GWE: Guidewire exchange; HD catheter: Hemodialysis catheter; HTS: Hypertonic saline; ICP: Intracranial pressure; ICU: Intensive Care Unit; IDSA: Infectious Disease Society of America; IJV: Internal jugular vein; IPC: Indian penal code; IRR: Incidence rate ratio; ISCCM: Indian Society of Critical Care Medicine; IV: Intravenous; LCBI: Laboratory confirmed blood stream infection; M/R: Minocycline/rifampicin; MBI-LCBI: Mucosal barrier injury laboratory-confirmed bloodstream infection; MRSA: Methicillin-resistant Staphylococcus aureus; NHS: National Health Service (UK); NHSN: National Healthcare Safety Network (USA); OT: Operation Theater; PICC: Peripherally-inserted central catheter; PIV: Peripheral intravenous line; PL: Peripheral line; PVI: Povidone-iodine; RA: Right atrium; RCT: Randomized controlled trial; RR: Relative risk; SCV/SV: Subclavian vein; ScVO2: Central venous oxygen saturation; Sn: Sensitivity; SOP: Standard operating procedure; SVC: Superior vena cava; TEE: Transesophageal echocardiography; UPP: Useful Practice Points; USG: Ultrasonography; WHO: World Health Organization.How to cite this article: Javeri Y, Jagathkar G, Dixit S, Chaudhary D, Zirpe KG, Mehta Y, et al. Indian Society of Critical Care Medicine Position Statement for Central Venous Catheterization and Management 2020. Indian J Crit Care Med 2020;24(Suppl 1):S6-S30.View full-textArticleReview of Strategies to Reduce Central Line-Associated Bloodstream Infection (CLABSI) and Catheter-A...November 2017 · Journal of Hospital Medicine Payal K. PatelAshwin GuptaValerie M Vaughn[...] Jennifer MeddingsCentral line-associated bloodstream infection (CLABSI) and catheter-associated urinary tract infection (CAUTI) are costly and morbid. Despite evidence-based guidelines, Some intensive care units (ICUs) continue to have elevated infection rates. In October 2015, we performed a systematic search of the peer-reviewed literature within the PubMed and Cochrane databases for interventions to reduce ... [Show full abstract] CLABSI and/or CAUTI in adult ICUs and synthesized findings using a narrative review process. The interventions were categorized using a conceptual model, with stages applicable to both CAUTI and CLABSI prevention: (stage 0) avoid catheter if possible, (stage 1) ensure aseptic placement, (stage 2) maintain awareness and proper care of catheters in place, and (stage 3) promptly remove unnecessary catheters. We also looked for effective components that the 5 most successful (by reduction in infection rates) studies of each infection shared. Interventions that addressed multiple stages within the conceptual model were common in these successful studies. Assuring compliance with infection prevention efforts via auditing and timely feedback were also common. Hospitalists with patient safety interests may find this review informative for formulating quality improvement interventions to reduce these infections.Read moreArticleCentral venous catheter insertion: Review of recent evidenceDecember 2020 · Baillière #x27 s Best Practice and Research in Clinical AnaesthesiologyLema Tomé MaríaGarrido Sánchez AlejandroPérez-Granda María JesúsGuidelines for prevention of catheter-related bloodstream infection (CR-BSI) describe a series of recommendations for correct insertion and handling of central venous catheters (CVCs).Since its implementation, quality programs as \"Zero bacteremia” have achieved a reduction in CR-BSI rates, but there is still room for further improvement. New evidence is emerging regarding e.g., ... [Show full abstract] antiseptic-antimicrobial impregnated catheters or the use of passive disinfection of closed connectors. These examples of new measures might help to further decrease infection rates. This article aims to review new evidence-based strategies to reduce catheter insertion related infection.Read moreArticleFull-text availableUltrasound-guided central venous catheter placement: First things firstDecember 2017 · Critical CareBernd SaugelLeonie Schulte-Uentrop Thomas W L Scheeren Jean-Louis TeboulView full-textArticleFailure of central venous catheter insertion and care bundles in a high central line–associated bloo...January 2020 · American Journal of Infection Control Amalia KarapanouAnna-Maria VieruMichail A. Sampanis[...] Michael SamarkosBackground: Our hospital has several characteristics different from the settings in which the central venous catheter (CVC) care bundle has been implemented so far, that is, care bundles or protocols are not systematically used, and the prevalence of central line-associated bloodstream infections (CLABSI) is high, as is bed occupancy rate. We examined the effectiveness of CVC care ... [Show full abstract] bundles.Methods: Modified CVC bundles were implemented across all settings of our hospital. During both phases of the study, we collected data on CLABSI, and we monitored CVC insertion and management practices with direct observation audits.Results: We have studied 913 CVC insertions (454 in PRE and 459 in POST) for 11,871 catheter-days. The incidence of CLABSI was 8.3 per 1,000 catheter-days PRE, and 7.6 per 1,000 catheter-days POST (incidence rate ratio, 0.92; 95% confidence interval, 0.60-1.40). Compliance with the CVC insertion bundle increased from 8.4%-74.3% (P .0001). The CVC management bundle compliance also increased from 11.4%-57.7% (P .0001).Conclusions: Despite improved compliance after the intervention, implementation of a modified CVC bundle failed to decrease CLABSI incidence. Higher bundle compliance rates may be necessary for a significant decrease in the incidence of CLABSI, along with the appropriate organizational culture and levels of staffing.Read moreDiscover the world s researchJoin ResearchGate to find the people and research you need to help your work.Join for free ResearchGate iOS AppGet it from the App Store now.InstallKeep up with your stats and moreAccess scientific knowledge from anywhere orDiscover by subject areaRecruit researchersJoin for freeLoginEmail Tip: Most researchers use their institutional email address as their ResearchGate loginPasswordForgot password? Keep me logged inLog inorContinue with GoogleWelcome back! Please log in.Email · HintTip: Most researchers use their institutional email address as their ResearchGate loginPasswordForgot password? Keep me logged inLog inorContinue with GoogleNo account? Sign upCompanyAbout usNewsCareersSupportHelp CenterBusiness solutionsAdvertisingRecruiting© 2008-2021 ResearchGate GmbH. 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