Dear Editor, Central venous catheterisation is a cornerstone of care in critically ill and trauma patients. Current guidelines and expert consensus recommend maximal aseptic precautions during central venous catheter insertion, including hand hygiene and the use of sterile gloves, gown, mask, cap, and large full-body drapes.1-3 While large-bore peripheral intravenous cannulation remains the appropriate first-line intervention for immediate crisis management, certain clinical scenarios necessitate central access even when standard resources are limited. These include patients in profound shock with collapsed peripheral veins where emergency access is unattainable, the mandatory initiation of potent inotropes or vasopressors in patients awaiting intensive care unit (ICU) transfer, or cases with exhausted peripheral access, such as in intravenous drug users. Although randomised data comparing maximal barrier precautions with limited barriers show varied results, it is well established that bundled aseptic practices including full sterile barriers are consistently associated with significantly reduced central line-associated bloodstream infections (CLABSIs) and remain the non-negotiable standard of care.2-4 In contrast, high-volume emergency triage areas and temporary holding zones for patients awaiting ward or ICU transfer frequently lack the infrastructure required for full guideline adherence. Space constraints, limited assistance, and restricted sterile supplies are common, and in many such settings, the only readily available sterile option for urgent internal jugular vein cannulation is a basic central line set comprising a small fenestrated drape and minimal instruments, without access to sterile gowns, full-body drapes, or dedicated ultrasound probe covers. Recognising that no adaptation should take precedence over established safety standards, we describe context-specific risk-mitigation strategies aimed at minimising breaches in sterility when ideal resources are physically unavailable. These pragmatic manoeuvres are designed to maintain a ‘zone of asepsis’ by physically preventing equipment from contacting unsterile surfaces. While we acknowledge that the impact of such bedside innovations on the true incidence of CLABSI remains to be validated through structured clinical research, they serve as a necessary safety bridge for clinicians balancing the urgency of access against the constraints of a resource-limited environment Table 1, Figure 1a and b.Figure 1: Improvised sterile handling technique for catheter: The Coiling technique: (a) When holding the central venous catheter; (b) When railroading the central venous catheter over the guidewireTable 1: Pragmatic adaptations for aseptic internal jugular vein cannulationPresentation at conferences/CMEs and abstract publication Nil. Disclosure of use of artificial intelligence (AI)-assistive or generative tools Nil. Declaration of use of permitted tools Nil. Financial support and sponsorship Nil. Conflicts of interest There are no conflicts of interest.
Goyal et al. (Thu,) studied this question.