Femoral vs. Jugular Venous Catheterization and Risk of Nosocomial Events in Adults Requiring Acute Renal Replacement Therapy - Cathedia Study

Description:

The goal of the trial was to evaluate rates of catheter colonization and bloodstream infection with jugular catheterization compared with femoral catheterization among intensive care unit patients undergoing acute renal replacement therapy.

Hypothesis:

Catheterization of the jugular vein for renal replacement therapy will be more effective in preventing catheter colonization and bloodstream infection.

Study Design

  • Randomized
  • Blinded
  • Parallel
  • Stratified

Patients Screened: 856
Patients Enrolled: 750
Mean Follow Up: Hospitalization
Mean Patient Age: 65 years
Female: 34

Patient Populations:

• Critically ill intensive care unit patients who were anticipated to undergo acute renal replacement therapy
• At least 18 years of age
• Suitable anatomy for jugular or venous catheterization

Exclusions:

• Prior venous catheterization for placement of a dialysis catheter
• Chronic renal failure with arteriovenous fistula
• Coagulopathy
• Morbid obesity (BMI >45 kg/m2)
• Local skin infection
• Inability to place the patient in Trendelenburg due to volume overload

Primary Endpoints:

Rates of catheter colonization upon removal

Secondary Endpoints:

Rates of catheter-related bloodstream infection and rates of catheter-related thrombosis

Drug/Procedures Used:

Intensive care unit patients who required acute renal replacement therapy were randomized to catheterization in the jugular vein (n = 375) or the femoral vein (n = 375).

Concomitant Medications:

Patients could receive heparin during the use of the dialysis catheter according to local practice.

Principal Findings:

At baseline, the mean body mass index (BMI) was 26.7 kg/m2, 71% of patients were ventilated, 60% were receiving antibiotics, and the median duration of catheter insertion was 5 days. In the jugular group, 29.8% of the patients died versus 26.5% in the femoral group.

The incidence of hematomas was 3.6% in the jugular group and 1.1% in the femoral group (p = 0.03). The rate of catheter colonization upon removal was 35.7 per 1,000 catheter days in the jugular group versus 40.8 per 1,000 catheter days in the femoral group (hazard ratio [HR] 0.85, p = 0.31). The rate of catheter-related bloodstream infection was 2.3 per 1,000 catheter days in the jugular group and 1.5 per 1,000 catheter days in the femoral group (p = 0.42). The rate of catheter-related thrombosis was 22.7% in the jugular group and 10.5% in the femoral group (p = 0.16).

The rate of catheter colonization was high with short-term use (≤5 days). For example, with jugular catheters, the rate of colonization was 78.8 per 1,000 catheter days for short-term use and 24.1 per 1,000 catheter days with longer use. With femoral catheters, the rate of colonization was 79.8 per 1,000 catheter days for short-term use and 27.3 per 1,000 catheter days with longer use.

There was significant heterogeneity according to BMI (p < 0.001). When the results were analyzed by BMI, there was a significant increase in catheter colonization among the jugular group with a BMI <24.2 kg/m2 (HR 2.1, p = 0.017), and a significant decrease among the jugular group with a BMI >28.4 kg/m2 (HR 0.40, p < 0.001).

Interpretation:

Among critically ill intensive care unit patients who are anticipated to undergo acute renal replacement therapy, the incidence of catheter colonization, catheter-related bloodstream infection, and thrombosis is similar between the jugular and femoral access sites. This finding is counter to the widely held belief that more infections are experienced with the femoral access site.

There were significantly more hematomas in the jugular group. The rate of catheter colonization was high with only short-term use (i.e., <6 days). A significant interaction was found with respect to BMI, where obese patients experienced more catheter colonization at the femoral site. This was in contrast to low BMI patients, where the femoral site appeared to be protective against catheter colonization. This study also calls into question the practice of changing catheters every 5 days, since there was a high rate of catheter colonization with only short-term use. These results should not be extrapolated to ambulatory patients with renal failure or the use of antibiotic impregnated catheters.

References:

Parienti JJ, Thirion M, M├ęgarbane B, et al. Femoral vs jugular venous catheterization and risk of nosocomial events in adults requiring acute renal replacement therapy: A randomized controlled trial. JAMA 2008;299:2413-22.

Presented at the 47th Interscience Conference on Antimicrobial Agents and Chemotherapy, Chicago, IL, September 2007.

Clinical Topics: Invasive Cardiovascular Angiography and Intervention

Keywords: Jugular Veins, Renal Insufficiency, Body Mass Index, Communicable Diseases, Thrombosis, Critical Illness, Femoral Vein, Hematoma, Catheterization, Central Venous, Renal Replacement Therapy, Catheter-Related Infections


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