For Dialysis Patients, Catheterization Sites Do Not Carry Very Different Infection Risks
May 28th, 2008 | by admin |According to new research published in the May 28 issue of JAMA,the location of catheter insertion - whether in a vein in a neck or ina vein in the upper leg - does not appear to change the risk ofinfection in critically ill patients who require dialysis. However,heavier patients were found to have a lower incidence of infection ifthey received catheterization in the neck rather than in the upper leg.
During critically ill patient care, there are 3 common places for apatient to receive catheterizations: the femoral vein in the upperinnerthigh, the jugular vein in the neck, and subclavian vein beneath theclavicle.Since these procedures are invasive, they often lead to additionalillness, death,and increased costs to treat complications and infections.Catheterization in the femoral vein is generally avoided and consideredan emergency procedure because of the high risk of complications, andthe subclavian vein siteis not equipped to handle larger catheters. The jugular site is usuallypreferred over the femoral site for short-term dialysis because of thejugular’s apparently lower risk of infection.
To compare infection risk between jugular and femoral catheterizations,Jean-Jacques Parienti, M.D., D.T.M. & H. (Cote de NacreUniversity Hospital Center, Caen, France) and colleagues conducted arandomized controlled trial to compare therates of catheter colonization at the time of catheter removal (asmeasured by bacteria growth on thecatheter) and the rates ofblood stream infections that are related to the catheter. Of 750severely ill patients in intensive care units(ICUs) in France who needed a catheter for acute renalreplacement therapy (dialysis), some were randomized toreceive jugular catheterizations and others to receive femoralvein catheterizations.
The main finding was that the risk of catheter colonization at the timeof catheter removal was not significantly different between the femoraland jugular groups. Per 1,000 catheter-days, 40.8% of the femoral groupand 35.7% of the jugular group had colonization. About 0.9% ofpatients (3 of 324) in the femoral group and 1.6% of patients (5 of313) in the jugular group had catheter-relatedbloodstream infections - not a statistically significant difference.
The authors note that, “[These results are] inconsistent with thewidely accepted conventionto avoid femoral catheterization to prevent the risk ofcatheter-related infection.”
However, patients in the jugular group were significantly more likelyto develop hematoma, or localized bleeding underneath the skin, thanpatients in the femoral group - 3.6% compared to 1.1%. Thosewith a body mass index (BMI) of less than 24.4 were twice as likely tosee catheter colonization if they were in the jugular group, and thosewith BMIs over 28.4 had a 60% lower incidence of colonization in thejugular group compared to the femoral group.
“In conclusion, the decision for the best site of insertion to preventcomplications might be more complex than previously suggested. Ourresults support the current guideline for preventing cathetercomplications regarding the optimal site for catheter insertion in theICU. If a subclavian approach is not available, and the … individualrisk of complications between the jugular and femoral sites is equal,the jugular site should be strongly considered for patients with higherBMI. We suggest that first-choice careful femoral catheterization by anexperienced operator with full sterile precautions and appropriatepost-insertion site care in non-obese, bed-bound, severely ill patientsis acceptable and could reduce catheter-related morbidity compared withjugular catheterization,” the authors conclude.
Femoral vs Jugular Venous Catheterization and Risk ofNosocomial Events in Adults Requiring Acute Renal Replacement Therapy:A Randomized Controlled Trial
Jean-Jacques Parienti; Marina Thirion; Bruno Mégarbane; BertrandSouweine; Abdelali Ouchikhe; Andrea Polito; Jean-Marie Forel; SophieMarqué; Beno?t Misset; Norair Airapetian; Claire Daurel; Jean-PaulMira; Michel Ramakers; Damien du Cheyron; Xavier Le Coutour; CédricDaubin; Pierre Charbonneau; for Members of the Cathedia Study Group
JAMA (2008). 299[20]:2413-2422.
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Written by: Peter M Crosta
Copyright: Medical News Today
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