Jugular vs. femoral central venous catheterization and risk of infection

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#IVTEAM #Intravenous literature: Timsit, J.F., Bouadma, L., Mimoz, O., Parienti, J.J., Garrouste-Orgeas, M., Alfandari, S., Plantefeve, G., Bronchard, R., Troche, G., Gauzit, R., Antona, M., Canet, E., Bohe, J., Herrault, M.C., Schwebel, C., Ruckly, S., Souweine, B. and Lucet, J.C. (2013) Jugular vs. Femoral Short-Term Catheterization and Risk of Infection in ICU Patients: Causal Analysis of 2 Randomized Trials. American Journal of Respiratory and Critical Care Medicine. October 15th. [epub ahead of print].

Abstract:

Rationale. When subclavian access is not possible, controversy exists for the choice of central-venous access in ICU patients, between the internal jugular and femoral sites.

Methods. Using data of 2 multicenter studies, we compared femoral and internal jugular for the risks of catheter-related-bloodstream infection(CR-BSI), major-catheter-related infection(M-CRI) and catheter-tip colonization. We also compared the rates of dressing disruption and skin colonization. We used marginal structural models with inverse-probability-of-treatment-weighting (IPTW) to adjust on indication bias.

Results. We included 2128 patients (2527 catheters and 19481 catheter-days). We found no difference in CR-BSI (internal jugular 1.0 vs. femoral 1.1/1000-catheter-days, HR=0.63(0.25 to 1.63),p=0.34), M-CRI (internal jugular 1.8 vs. femoral 1.4/1000-catheter-days, HR=0.91(0.38 to 2.18),p=0.34) and colonization (internal jugular 11.6 vs. femoral 12.9/1000-catheter-days, HR=0.80(0.25 to 1.63),p=0.15). However, colonization was higher with femoral for female (HR=0.39(0.24 to 0.63),p<0.001) and, at the significance limit, catheter maintained for more than 4 days (HR=0.73(0.53 to 1.01),p=0.05). The absence of benefit of internal jugular before day 5 was related to a higher skin colonization at the internal jugular site for catheters removed before day 5. After the 4thday, dressing disruption became more frequent with femoral catheters and may explain the subsequent risk of catheter colonization. Differences in cutaneous and catheter colonization between internal jugular and femoral was suppressed by the use of chlorhexidine (CHG) impregnated dressings.

Conclusion. femoral and internal jugular accesses lead to similar risks of catheter infection internal jugular might be preferred for female, non-CHG impregnated dressings users, and when catheters are left in place more than 4 days. Both sites are acceptable when a subclavian approach is not feasible. Clinical trial registration information available at www.clinicaltrials.gov, i.d. codes NCT00417235 and NCT01189682.

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