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 in a vein in the upper leg – does not appear to change the risk of infection in critically ill patients who require dialysis. However, heavier patients were found to have a lower incidence of infection if they received catheterization in the neck rather than in the upper leg.
During critically ill patient care, there are 3 common places for a patient to receive catheterizations: the femoral vein in the upper inner thigh, the jugular vein in the neck, and subclavian vein beneath the clavicle. Since these procedures are invasive, they often lead to additional illness, death, and increased costs to treat complications and infections. Catheterization in the femoral vein is generally avoided and considered an emergency procedure because of the high risk of complications, and the subclavian vein site is not equipped to handle larger catheters. The jugular site is usually preferred over the femoral site for short-term dialysis because of the jugular’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 Nacre University Hospital Center, Caen, France) and colleagues conducted a randomized controlled trial to compare the rates of catheter colonization at the time of catheter removal (as measured by bacteria growth on the catheter) and the rates of blood stream infections that are related to the catheter. Of 750 severely ill patients in intensive care units (ICUs) in France who needed a catheter for acute renal replacement therapy (dialysis), some were randomized to receive jugular catheterizations and others to receive femoral vein catheterizations.
The main finding was that the risk of catheter colonization at the time of catheter removal was not significantly different between the femoral and jugular groups. Per 1,000 catheter-days, 40.8% of the femoral group and 35.7% of the jugular group had colonization. About 0.9% of patients (3 of 324) in the femoral group and 1.6% of patients (5 of 313) in the jugular group had catheter-related bloodstream infections – not a statistically significant difference.
The authors note that, “[These results are] inconsistent with the widely accepted convention to avoid femoral catheterization to prevent the risk of catheter-related infection.”
However, patients in the jugular group were significantly more likely to develop hematoma, or localized bleeding underneath the skin, than patients in the femoral group – 3.6% compared to 1.1%. Those with a body mass index (BMI) of less than 24.4 were twice as likely to see catheter colonization if they were in the jugular group, and those with BMIs over 28.4 had a 60% lower incidence of colonization in the jugular group compared to the femoral group.
“In conclusion, the decision for the best site of insertion to prevent complications might be more complex than previously suggested. Our results support the current guideline for preventing catheter complications regarding the optimal site for catheter insertion in the ICU. If a subclavian approach is not available, and the … individual risk of complications between the jugular and femoral sites is equal, the jugular site should be strongly considered for patients with higher BMI. We suggest that first-choice careful femoral catheterization by an experienced operator with full sterile precautions and appropriate post-insertion site care in non-obese, bed-bound, severely ill patients is acceptable and could reduce catheter-related morbidity compared with jugular catheterization,” the authors conclude.
Femoral vs Jugular Venous Catheterization and Risk of Nosocomial Events in Adults Requiring Acute Renal Replacement Therapy: A Randomized Controlled Trial
Jean-Jacques Parienti; Marina Thirion; Bruno Mégarbane; Bertrand Souweine; Abdelali Ouchikhe; Andrea Polito; Jean-Marie Forel; Sophie Marqué; Benoît Misset; Norair Airapetian; Claire Daurel; Jean-Paul Mira; Michel Ramakers; Damien du Cheyron; Xavier Le Coutour; Cédric Daubin; Pierre Charbonneau; for Members of the Cathedia Study Group
JAMA (2008). 299[20]:2413-2422.
Written by: Peter M Crosta