Clinical practice guidelines for the management of central venous catheter for critically ill patients
The objective of this article is to provide a guideline for the management of central venous catheter for critically ill patients. Electronic databases of CENTRAL, CINAHL, EMBASE, four Chinese databases (CBM, WANFANG DATA, CAJD, VIP Database) and Google Scholar were searched from inception to August 2017. The reviewers assessed each included study for the risk of bias under the Grading of Recommendations, Assessment, Development, and Evaluation (GRADE) framework. The GRADE evidence profile tables were added to each important clinical outcome. The guideline will be updated in a 5-year interval by incorporating new evidence. The guideline panel provided 11 statements on the management of central venous catheter for critically ill patients. Overall, there were 4 strong recommendations, and 7 weak recommendations. They were as follows: (I) we commend the use of catheter impregnation to prevent catheter-related blood stream infection (1A); (II) we suggest the use of real-time ultrasound guidance for subclavian or femoral vein insertion (2B), and recommend that for internal jugular vein (1A); (III) we suggest the use of real-time color Doppler ultrasound guidance on central venous catheterization for adult and pediatric patients (2C); (IV) we suggest not to use heparin for the maintenance of CVC patency (2A); (V) we suggest the use contrast-enhanced ultrasound for the confirmation of central venous catheter placement (2B); (VI) we recommend the use of bedside ultrasound together with agitated or non-agitated normal saline to confirm CVC position (1C); (VII) we suggest to use subclavian site for CVC insertion (2C); (VIII) we suggest not to use heparin-bonded catheters or warfarin to prevent CVC-related deep vein thrombosis in children (2D); (IX) we recommend the implementation of central-line bundles to reduce the risk of CRBSI for adult, pediatric and neonatal ICUs (1B); (X) we suggest skin antisepsis with chlorhexidine throughout in-dwelling period for reducing CVC-related infections (2D); (XI) we recommend a differential time to positivity (DTP) of blood cultures from CVC and peripheral vein of 120 minutes to diagnose CRBSI (1B). Substantial agreement exists among experts for issuing strong recommendations for the management of central venous catheter. Although a significant number of aspects of care have relatively weak support, evidence-based recommendations regarding the management of central venous catheter are the foundation of improved outcomes for critically ill patients.