The SIC protocol: A seven-step strategy to minimize complications potentially related to the insertion of centrally inserted central catheters

Abstract

Insertion of central venous catheters in the cervico-thoracic area is potentially associated with the risk of immediate/early untoward events, some of them negligible (repeated punctures), some relevant (accidental arterial puncture), and some severe (pneumothorax). Furthermore, different strategies adopted during insertion may reduce or increase the incidence of late catheter-related complications (infection, venous thrombosis, dislodgment). This paper describes a standardized protocol (S.I.C.: Safe Insertion of Centrally Inserted Central Catheters) for the systematic application of seven basic beneficial strategies to be adopted during insertion of central venous catheters in the cervico-thoracic region, aiming to minimize immediate, early, or late insertion-related complications. These strategies include: preprocedural evaluation, appropriate aseptic technique, ultrasound guided insertion, intra-procedural assessment of the tip position, adequate protection of the exit site, proper securement of the catheter, and adequate coverage of the exit site.

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https://doi.org/10.1177/11297298211036002
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Vascular Access
Introduction
The insertion of Centrally Inserted Central Catheters
(CICC) is a widely used procedure in clinical practice, cur-
rently associated with a decreased risk of complications
than in the past. Many factors have contributed to improve
the safety of this clinical practice, the most important
being the increasingly widespread use of ultrasound (US)
in the different phases of CICC insertion. Ultrasound may
be used for the preliminary assessment of veins, real-time
venipuncture, and immediate detection of possible punc-
ture-related complications (such as tissue hematomas,
intramural hematomas of the vein, pneumothorax, others).
Ultrasound also allows for “tip navigation” (i.e. to verify
the correct direction of the guidewire and/or catheter while
they progress into the vascular system), for “tip location”
(i.e. to assess the central position of the tip), and for the
diagnosis of many late non-infective complications
(fibroblastic sleeve, catheter-related venous thrombosis,
tip migration, others).1–8
Ultrasound is of paramount importance but is not the
unique solution for the reduction of all catheter-related
The SIC protocol: A seven-step
strategy to minimize complications
potentially related to the insertion of
centrally inserted central catheters
Fabrizio Brescia1, Mauro Pittiruti2, Matthew Ostroff3,
Timothy R Spencer4 and Robert B Dawson5
Abstract
Insertion of central venous catheters in the cervico-thoracic area is potentially associated with the risk of immediate/
early untoward events, some of them negligible (repeated punctures), some relevant (accidental arterial puncture), and
some severe (pneumothorax). Furthermore, different strategies adopted during insertion may reduce or increase the
incidence of late catheter-related complications (infection, venous thrombosis, dislodgment). This paper describes a
standardized protocol (S.I.C.: Safe Insertion of Centrally Inserted Central Catheters) for the systematic application of
seven basic beneficial strategies to be adopted during insertion of central venous catheters in the cervico-thoracic region,
aiming to minimize immediate, early, or late insertion-related complications. These strategies include: preprocedural
evaluation, appropriate aseptic technique, ultrasound guided insertion, intra-procedural assessment of the tip position,
adequate protection of the exit site, proper securement of the catheter, and adequate coverage of the exit site.
Keywords
Techniques and procedures, ultrasound guidance, standardized assessment, central venous access, patient safety,
centrally inserted central catheters
Date received: 20 May 2021; accepted: 12 July 2021
1 Unit of Anesthesia and Intensive Care Medicine, Vascular Access
Team, Centro di Riferimento Oncologico di Aviano, IRCCS, Aviano,
Italy
2 Department of Surgery, Fondazione Policlinico Universitario
“A.Gemelli” IRCCS, Rome, Italy
3Saint Joseph’s University Medical Center, Paterson, NJ, USA
4Global Vascular Access, LLC, Scottsdale, AZ, USA
5 Catholic Medical Center – Upper Connecticut Valley Hospital,
Colebrook, NH, USA
Corresponding author:
Fabrizio Brescia, Unit of Anesthesia and Intensive Care Medicine,
Vascular Access Team, Centro di Riferimento Oncologico di Aviano,
IRCCS, Via Gallini 2, Aviano 33081, Italy.
Email: fabriziobrescia@gmail.com
1036002JVA0010.1177/11297298211036002The Journal of Vascular AccessBrescia et al.
editorial2021
Editorial

2 The Journal of Vascular Access 00(0)
complications. Other evidence-based strategies (proper
choice of the exit site, skin antisepsis with 2% chlorhex-
idine in alcohol, maximal barrier precautions, intracavitary
ECG for tip positioning, sutureless securement, others) are
also known to increase the safety and the cost-effective-
ness of the procedure.1–5
An insertion bundle consists of clear recommendations
based on scientific evidence, capable of acting synergisti-
cally to provide maximal safety, positive outcomes, and
cost-effectiveness of a given procedure. When placing a
CICC, the purpose of an insertion bundle is to minimize
any complication directly or indirectly related to the
maneuver (accidental injury, incorrect tip location, arrhyth-
mias, catheter-related venous thrombosis, catheter-related
infections, others).
A similar insertion bundle has already been proposed
for peripherally inserted central catheters (PICCs), the
so-called SIP protocol.9 In the following paragraphs, the
authors will describe a seven-step strategy for minimiz-
ing insertion-related complications associated with
CICCs, the “SIC” protocol (Safe Insertion of Central
Catheters). It consists of seven different steps which
summarize those evidence-based recommendations that,
if applied correctly and systematically, allow to guaran-
tee a safe, successful, and cost-effective procedure
(Table 1).
Preprocedural evaluation: The rapid central
vein assessment (RaCeVA) and the central
zone insertion method (Central ZIM)
Proper pre-procedural evaluation obviously begins with an
adequate anamnestic evaluation. It is important to consider
whether the patients had previous vascular devices or
repeated difficult venipunctures. Also, it is important to
evaluate the patient’s coagulation and platelet status,
although the incidence of major bleeding complications
after central venous catheter placement is low, even in
coagulopathic patients.10
Before starting the procedure, two important issues of
concern are the selection of the appropriate vein and the
location of the exit site of the catheter.
The choice of the vein must be carefully considered
before proceeding with CICC insertion. The preference or
personal experience of the operator should not be consid-
ered as adequate criteria, as they do not guarantee maximal
safety for the patient. On the contrary, a rational and objec-
tive systematic evaluation of the anatomical characteristics
of the vascular system of each patient is possible through
adoption of a pre-procedural ultrasound scan of the ana-
tomical area in which the central venous access device will
be inserted.11
The Rapid Central Vein Assessment (RaCeVA) proto-
col is a systematic approach of US evaluation of the veins
of the neck and of the supra/infraclavicular area before
CICC insertion.12 RaCeVA follows a series of steps that
can be performed in a short time, and should always be
performed bilaterally. The RaCeVA is designed for an
easy, rapid, and systematic assessment of the six central
veins that can be theoretically punctured and cannulated
by US in the supra/infraclavicular area: internal jugular
vein (IJV), external jugular vein (EJV), brachiocephalic
vein (BCV), and subclavian vein (SV) in the supraclavicu-
lar area; axillary vein (AV) and cephalic vein (CV) in the
infraclavicular area. During the RaCeVA, the operator can
rule out venous abnormalities such as thrombosis, steno-
sis, external compression, anatomical variations of size
and shape of the veins, choose an appropriate catheter/vein
(ideal 1:3 or less) so to reduce the risk of catheter-related
thrombosis, and obtain a full anatomic evaluation for opti-
mum site selection and the best insertion approach for each
patient.2,12,13 Also, RaCeVA visualizes the surrounding
arterial or nervous structures that could be accidentally
injured during venous catheterization.12 The seventh and
last step of RaCeVA involves the assessment of pleural
space in the pre-insertion phase, providing an accurate
baseline assessment of pleural function prior to the inser-
tion of a CICC.12 This protocol is useful for teaching the
Table 1. The seven steps of the SIC protocol.
Step 1 Preprocedural evaluation—choice of the vein by systematic ultrasound examination of the veins of the neck and of the
supra/infraclavicular region (RaCeVA protocol) and choice of the ideal exit site (Central ZIM)
Step 2 Appropriate aseptic technique—hand hygiene, skin antisepsis with 2% chlorhexidine in 70% alcohol, maximal barrier
precautions
Step 3 Ultrasound-guided insertion—ultrasound-guided venipuncture, ultrasound verification of the correct direction of the
guidewire (tip navigation) and of the absence of pneumothorax (pleural scan)
Step 4 Intra-procedural assessment of tip location—verification of the central position of the tip by intracavitary ECG and/or by
transthoracic echocardiography, using the “bubble test”
Step 5 Adequate protection of the exit site—reduction of the risk of bleeding and risk of contamination by sealing with
cyanoacrylate glue
Step 6 Proper securement of the catheter—stabilization of the catheter using skin-adhesive sutureless devices, transparent
dressing with integrated securement or subcutaneous anchorage
Step 7 Appropriate coverage of the exit site—use of semi-permeable transparent dressing, preferably with high breathability

Brescia et al. 3
different US-guided approaches to the central veins.
RaCeVA ensures the operator systematically considers all
possible venous options allowing the most appropriate
vein to be accessed while also maintaining the patient
safety benefits.
The risk of infection or dislodgment of a central venous
access also depends on the choice of the exit site. This pro-
tocol suggests the opportunity of applying Dawson’s14
Zone Insertion Method (ZIM) for Peripherally Inserted
Central Catheters (PICCs) to the cervico-thoracic region
(so called “Central ZIM”). As demonstrated in the arm, the
cervico-thoracic region can be divided into three different
zones, red, yellow, and green, that correspond to the neck,
supraclavicular and infraclavicular regions (Figure 1).
The red zone is an area with high bacterial contamina-
tion of the skin, due to the proximity of the oropharyngeal
secretions. It is also an area with a high risk of catheter
dislodgment because of the movements of the neck. For
this reason, the neck region is to be avoided both as a veni-
puncture site and as an exit site.
The yellow zone corresponds to the supraclavicular
area, where US-guided venipuncture of internal jugular,
external jugular, brachio-cephalic, or subclavian vein is
feasible. An exit site in the supraclavicular area is accept-
able but not always ideal.
The green zone corresponds to the infraclavicular area,
where US-guided venipuncture of axillary or cephalic vein
is usually feasible. An exit site in the infraclavicular area is
ideal because of the low bacterial contamination and the
low risk of dislodgment.
Therefore, an optimal venipuncture site may not corre-
spond to an ideal exit site (Figure 2(a) and (b)).
Tunneling is a strategy that enables movement of the
catheter away from an area at high risk of infection or dis-
lodgment toward a safer exit site, providing both an opti-
mal insertion site and an optimal location of the exit site.15
As regards to CICC insertion, two main types of tunneling
are particularly useful: tunneling from the supraclavicular
area to the infraclavicular area (tunneling type A) (Figure
3(a)) and tunneling from the infraclavicular area to the
breast area (tunneling B) (Figure 3(b)). The latter might be
useful, for example, in patients with skin problems of the
chest area or in patients with tracheostomy (i.e. when it to
advisable to place the exit site as far as possible from res-
piratory or oral secretions).
For the tunneling of the catheter, it is preferable to use
blunt tunnelers, as they are associated with minimal risk of
local bleeding even in patients with coagulation disorders
or with reduced platelet counts.16
In short, RaCeVA permits clinicians to choose the opti-
mal venipuncture site while the Central ZIM compliments
RaCeVA to plan the optimal exit site.
Appropriate aseptic technique
The second very important step concerns the aseptic tech-
nique to be used during the placement of a CICC. Hand
hygiene must be preferably performed with hydroalco-
holic gel. In special cases, or when the hands are visibly
dirty, the hydroalcoholic gel must be preceded by washing
with soap and water, according to current international
infection prevention guidelines. For skin antisepsis, 2%
chlorhexidine in 70% alcohol should be used: iodine povi-
done in alcohol has a role only in case of known allergy to
chlorhexidine. Regarding the antiseptic application tech-
nique, no clinical difference in microorganism reduction
between the concentric circle and the back-and-forth tech-
niques has been documented, both techniques should be
used equally on clean and healthy skin.17
As recommended by all current guidelines, the risk of
bacterial contamination must be reduced by adopting the
maximal barrier precautions, non-sterile cap, non-sterile
mask, sterile gown, sterile gloves, full-size sterile drape
over the patient, plus adequate sterile protection of the
ultrasound probe that is long enough to cover the probe
and the ultrasound wire.2,4,18,19
Ultrasound-guided insertion
Ultrasound-guided venipuncture is considered mandatory
for any central venous catheterization.1 In the supraclav-
icular area, the IJV can be accessed by ultrasound guid-
ance, preferably with vein visualization in short axis and
in-plane puncture, so as to minimize any risk of arterial
injury. Other possible approaches in the supraclavicular
are the ultrasound-guided venipuncture of BCV, SV, or
EJV, with vein visualization in long axis and in-plane
puncture.12
In the infraclavicular area, the axillary vein can be visu-
alized in short axis, in long axis, or in oblique axis. The
oblique axis view is obtained rotating the probe to almost
halfway between the short axis and the long axis view.
Figure 1. Central Zone Insertion Method.

4 The Journal of Vascular Access 00(0)
This oblique axis approach visualizes the axillary vein, the
axillary artery, the pleura, and the other surrounding struc-
tures, making possible to perform a safe in-plane puncture.
The oblique axis + in-plane technique combines the
advantages of the panoramic view with the optimal visu-
alization of the needle tip obtained by the in-plane
puncture.20,21
The authors recommend the use of a micro-introducer
kit consisting of a 21G echogenic needle (for minimally
invasive venipuncture), a 0.018″ nitinol guidewire with
straight soft tip, and a micro-introducer/dilator allows a
less traumatic vein dilation.
Soon after the ultrasound-guided venipuncture, ultra-
sound should also be used for assessing the correct direc-
tion of the guidewire toward the SVC (ultrasound-based
“tip navigation,” by scanning the veins of the supraclavic-
ular area), and for ruling out pneumothorax, by detecting
the “sliding sign” in the pleural space or other ultrasound
signs that exclude the presence of pneumothorax such as
the “seashore sign” using M-mode.13,22 Both maneuvers
can be performed with the same linear probe used for veni-
puncture. Assessment of the absence of ultrasound signs
suggestive of pneumothorax should be performed after
any central venipuncture.12
Intra-procedural assessment of tip location
The fourth important step of the SIC bundle is the intraproce-
dural assessment of the central position of the tip (“tip loca-
tion”). Post-procedural control of tip location is discouraged
by current guidelines,4 as it is associated with inefficiencies in
procedural time and resources, as well as potential harm to
the patient. The most cost-effective and accurate intra-proce-
dural method for tip location is intracavitary ECG.23
Fluoroscopy is an acceptable intra-procedural method, but is
often inaccurate, expensive, logistically difficult, and even
unsafe as it exposes patients and operators to ionizing radia-
tion.4 The applicability of the intracavitary ECG method has
also been extended more recently to atrial fibrillation
patients.24 Intracavitary ECG has some limitations of applica-
bility, for example in those situations in which the patient has
no atrial fibrillation, but the P wave is nonetheless not evident,
because of a pacemaker or some other abnormalities of car-
diac rhythm. In these cases, another effective, inexpensive,
Figure 3. (a) Tunneling of from supraclavicular area to infraclavicular area (b) Tunneling of from infraclavicular area to breast area.
Figure 2. (a) Venipuncture site for US guided CICCs (b) Exit-site for US guided CICCs.

Brescia et al. 5
and non-invasive intraprocedural method for tip location is
transthoracic echocardiography using the “bubble test” (a
rapid infusion of a few milliliters of “agitated” saline solution
that allows for better visualization of the catheter tip).1,13,25,26
Adequate protection of the exit site
The choice of an adequate exit site constitutes the first part of
a series of actions that make it possible to protect it. Tunneling
is a fundamental technique that allows to choose the appro-
priate exit site and the most suitable venipuncture site.4
At the time of CICC insertion, the best protection of the
exit site from bleeding and from extraluminal bacterial con-
tamination is the sealing with a cyanoacrylate glue. In addi-
tion, glue may reduce “micro-movements” of the catheter at
the exit site, reducing local damage to the endothelium of
the vein, potentially reducing the risk of intravenous throm-
bus formation.27 Gilardi et al.28 recommend using glue only
at the time of insertion; at the first dressing change, antibac-
terial protection of the exit site will be ensured using chlo-
rhexidine-impregnated sponge dressing. In the case of
tunneling, glue will also be used for closing the skin at the
site of venipuncture and tunneling puncture points.
Proper securement of the catheter
Securement by sutures is discouraged by all current
guidelines.3,4,6,19 Suture-based securement of venous access
devices is associated with high risk of exit site infection and
catheter dislodgment, as well as risk of accidental needle-
stick puncture for the operator. Current alternative options
for securement are skin-adhesive sutureless devices, trans-
parent dressing with integrated securement, and subcutane-
ous anchorage. In any patients at high risk for catheter
dislodgment (non-collaborative patients, skin abnormalities,
relevant perspiration, others) it is preferable to use a subcuta-
neously anchored sutureless device.29,30 Subcutaneously
anchored securement is safer and more effective than skin-
adhesive devices. It is also theoretically associated with less
risk of infection, since it allows more complete skin antisep-
sis around the exit site.29–32
Exit site coverage
The exit site should always be covered with a semi-perme-
able transparent dressing—preferably with a high breatha-
bility factor—so to ensure adequate protection of the exit
site and stabilization of the catheter. Appropriate catheter
securement and appropriate protection of the exit site are
key factors for reducing the incidence of dislodgment,
infection, and venous thrombosis.3,4
Conclusions
When placing a CICC, a certain number of evidence-based
strategies will protect against the risk of insertion-related
complications, either immediate (puncture failure, arterial
injury, hematoma, nerve injury, pneumothorax, hemotho-
rax, others) or early (arrhythmias, dislodgment, tip malpo-
sition, others) or late (infection, venous thrombosis,
others). These safe and beneficial strategies include the
use of ultrasound in different phases of the maneuver
(choice of the vein, venipuncture, tip navigation, tip loca-
tion, others), the adoption of standardized protocols for
choosing the vein (RaCeVA) and the exit site (Central
ZIM), the adoption of proper measures for infection pre-
vention (hand hygiene, skin antisepsis with 2% chlorhex-
idine in alcohol, maximal barrier precautions), the
preferential use of intracavitary ECG for catheter tip loca-
tion, and an appropriate protocol for sutureless securement
and exit site protection. In this regard, the adoption of
cyanoacrylate glue and subcutaneously anchored suture-
less device may be a perfect combination in terms of
cost-effectiveness.
Many complications, even some late complications, are
caused by wrong choices at the time of insertion. For
example, avoidance of ultrasound-guided venipuncture
may increase the risk of accidental arterial puncture and
pneumothorax. Failure to verify the proper location of the
tip may increase the risk of venous thrombosis. The choice
of a suboptimal exit site may expose the device to bacterial
contamination increasing the infectious risk.1–8 The use of
a standardized, systematic protocol—such as the one
described here—may improve the performance of CICC
insertion. The consistent and systematic adoption of all
seven recommendations of the SIC protocol will help to
save time and resources, safeguarding patient safety, and
ensuring cost-effectiveness.
Declaration of conflicting interests
The author(s) declared no potential conflicts of interest with
respect to the research, authorship, and/or publication of this
article.
Funding
The author(s) received no financial support for the research,
authorship, and/or publication of this article.
ORCID iDs
Fabrizio Brescia https://orcid.org/0000-0002-6892-474X
Mauro Pittiruti https://orcid.org/0000-0002-2225-7654
Matthew Ostroff https://orcid.org/0000-0001-5417-5621
Timothy R Spencer https://orcid.org/0000-0002-3128-2034
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