Table 2.
Recommendations list of Indian Society of Critical Care Medicine Position Statement for Central Venous Catheterization and Management 2020.
| S/no. | Statement | GOR, LOE |
| 1. Resource preparation A. Indications of central venous catheterization | ||
| 1 | We recommend central venous catheterization after understanding clear indication | A, 3 |
| 2 | We suggest CVC when hyperosmolar and locally irritant agents are to be administered | B, UPP |
| 3 | We recommend CVC use for vasoactive drugs unless the risk outweighs benefit of placing a CVC and delaying the therapy | A, 3 |
| B. CVC catheterization in locations other than ICU | ||
| 1 | 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 document | A, UPP |
| 2 | We recommend that all units performing central venous cannulation should have a quality improvement program in place with follow-up of outcomes | A, UPP |
| 3 | We recommend that daily review for the necessity of CVC should be done at all care sites | A, 2 |
| C. Central venous catheter site selection | ||
| 1 | We recommend In emergency scenarios, insertion site selection should be based on patient factors, clinical need, practitioner judgment, experience and skills | A, 3 |
| 2 | We suggest subclavian insertion site should be preferred over IJV and femoral for central venous catheterization to decrease infectious and thrombotic complications | B, 2 |
| 3 | We recommend subclavian vein to be avoided in patient with coagulopathy, distorted anatomy, and who may have high chances of mechanical complications | A, 2 |
| 4 | We recommend that in case of burns, extensive skin loss and superficial infections, CVC insertion should be done where the skin is intact | A, UPP |
| 5 | We suggest Internal Jugular CVC lines could safely be inserted in adult neurocritical care patients | B, 2 |
| D. Catheter selection | ||
| 1 | We suggest to use a CVC with the minimum number lumens needed for patient management | B, 3 |
| 2 | No recommendation can be made for designated lumen for parenteral nutrition. Unresolved issue | B, 3 |
| 2. CVC—Infection control A. Site selection | ||
| 1 | We suggest evaluating risk-to-benefit ratio of infectious and mechanical complications before choosing a particular insertion site | B, 2 |
| 2 | We recommend avoiding using femoral vein for the routine placement of central venous catheters | A, 2 |
| B. Hygiene practices, barrier precautions, and skin preparation | ||
| 1 | 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 CVC | A, 2 |
| 2 | We recommend maintaining aseptic technique for insertion and maintenance of CVC | A, 2 |
| 3 | We recommend maximal sterile barrier (MSB) precautions before any insertion (de novo or exchange over guidewire) of CVC | A, 1 |
| 4 | We recommend wearing either clean or sterile gloves when handling or dressing the CVC | A, 3 |
| 5 | We recommend preparation and cleaning of the skin site with an alcoholic chlorhexidine solution containing a concentration more than 0.5% chlorhexidine and 70 % alcohol before central venous catheter insertion and during dressing changes | A, 1 |
| 6 | We suggest to use tincture of iodine, an iodophor, or 70 % alcohol use as alternatives if chlorhexidine is contraindicated | B, 3 |
| 7 | We recommend allowing the skin antiseptic to dry completely before catheter insertion | A, 2 |
| C. CVC Fixation | ||
| 1 | No recommendation can be made for preference of securing system and operator or local practice based decision should be taken. | B, 3 |
| D. Port utilization and maintenance | ||
| 1 | We recommend disinfecting catheter hubs, needleless connectors, taps and injection ports before accessing the catheter using an alcoholic chlorhexidine preparation or 70 % alcohol | A, 2 |
| 2 | We recommend wearing either clean or sterile gloves when handling the hub and catheter | A, 3 |
| E. Prophylactic antibiotics and antiseptics | ||
| 1 | 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 |
| 2 | We recommend the use of chlorhexidine soaked sponge or dressing at the catheter exit site to prevent CRBSI | A, 1 |
| 3 | We recommend daily Chlorhexidine Bed Bath[sponging] for patients in ICU to reduce CRBSI incidence | A, 1 |
| 4 | We suggest antibiotic lock solutions to prevent CRBSI only in selected conditions, which are as follows:
|
B, 2 |
| 5 | We recommend against systemic intravenous antibiotics in prevention of CRBSI | A, 1 |
| F. Removal of Central line | ||
| 1 | We recommend removing central venous catheter as soon as its indication ceases | A, UPP |
| 2 | We suggest not routinely replacing or relocating the central venous lines unless clinically indicated | B, UPP |
| 3 | We recommend each institute to have central venous catheter removal protocol and only staff trained in the same should remove central line | A, UPP |
| G. Catheters impregnated with antiseptics and antibiotics | ||
| 1 | We recommend using M/R or C/SS coated CVCs when catheter is expected to be in use for more than five 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, 1 |
| 3. Prevention of mechanical complications A. Role of sonography | ||
| 1 | Wherever available we recommend US guidance to improve success rate, patient safety and procedural quality and reduce mechanical complications during CVC placement | A, 2 |
| B. Guidewire exchange | ||
| 1 | We suggest exchange of malfunctioning CVC over guidewire in selected patients with no evidence of infection | B, 2 |
| C. Tip positioning | ||
| 1 | We recommend post-procedure, position of the catheter tip must be assessed | A, UPP |
| 2 | 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 |
| 3 | We recommend the use of chest X-ray to assess the CVC catheter tip position | A, 2 |
| 4. Surveillance A. Infection control | ||
| 1 | We recommend against routine replacement of CVCs to prevent catheter-related infections | A, 1 |
| 2 | We recommend prompt removal of CVC when it is not essential | A, 2 |
| 3 | We recommend against routine catheter tip cultures for purpose of surveillance | A, 2 |
| 4 | We recommend that routine practice bundle (Appendix II) should be followed to reduce CVC-related infections. | A, 1 |
| B. Surveillance of mechanical complications | ||
| 1 | We recommend Chest X-ray post insertion of IJ and SC central line | A, 2 |
| 2 | We suggest that ultrasound guidance can be used for early identification of mechanical complication | B, 2 |
| C. Education, training, CQI initiatives, and audit Education and training | ||
| 1 | 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 |
| 2 | 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 CVC | A, 1 |
| 3 | We suggest providing appropriate and adequate nursing care to improve CVC-related outcomes | B, 2 |
| CQI initiatives | ||
| 1 | We recommend using institutional CQI initiatives with bundled approach for performance improvement | A, 2 |
| Audit tools | ||
| 1 | We recommend conducting surveillance to determine CLABSI rates, monitor its trends and identify lapses in infection control practices | A, 1 |
| 2 | We do not recommended routine culture of catheter tip for purpose of surveillance | A, 1 |
| 3 | DTTP is the recommended method of diagnosis for CVC-related infections in patients | A, 2 |
| 4 | We suggest recording the operator, date and time of catheter insertion and removal and dressing changes on a standardized form | A, UPP |
| D. Consent and medicolegal issues | ||
| 1 | We suggest that a structured Credentialing process be in place for personnel involved in insertion and maintenance of CVC | B, UPP |