For critically ill patients requiring dialysis, insertion of the catheter in a vein in the neck does not appear to reduce the risk of infection compared to vein access in the upper leg, except for patients at higher weight levels, according to a study in the May 28 issue of JAMA.
Catheterizations involving the femoral vein (in the upper, inner thigh), jugular vein (in the neck) and subclavian vein (beneath the clavicle) are routinely performed during critically ill patient care. These invasive procedures can contribute to additional illness, death and costs from complications and infections. Femoral venous catheterization is considered an emergency procedure that should be avoided if possible because of complication risks. The subclavian site is less suitable for larger catheters. Based on concerns about the risk of infection, the jugular site is often preferred over the femoral site for short-term dialysis, according to background information in the article.
Jean-Jacques Parienti, M.D., D.T.M. & H., of the Cote de Nacre University Hospital Center, Caen, France, and colleagues compared the rates of catheter colonization (growth of bacteria on the inserted catheter, detected at the time of catheter removal) and the rates of catheter-related blood stream infections between jugular and femoral catheterization among 750 severely ill patients in intensive care units (ICUs) in France who required a catheter insertion for acute renal replacement therapy (i.e., dialysis). Patients were randomized to receive jugular or femoral vein catheterization.
The risk of catheter colonization at the time of catheter removal did not differ significantly between the femoral and jugular groups (incidence of 40.8 vs. 35.7 per 1,000 catheter-days). Catheter-related bloodstream infection occurred in 3 of 324 patients (0.9 percent) with femoral catheters and in 5 of 313 patients (1.6 percent) with jugular catheters, a difference that was not statistically significant.
“[These results are] inconsistent with the widely accepted convention to avoid femoral catheterization to prevent the risk of catheter-related infection,” the authors write.
The rate of hematoma formation (localized area of bleeding beneath the skin) was significantly higher for patients in the jugular catheterization group (3.6 percent) compared with those in the femoral catheterization group (1.1 percent).
Patients with a lower body mass index (BMI; less than 24.2) had twice the risk of catheter colonization in the jugular vs. femoral group, while patients with a higher BMI (greater than 28.4) had a 60 percent lower incidence of catheter colonization in the jugular vs. 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 researchers write.
(JAMA. 2008;299[20]:2413-2422. Available pre-embargo to the media at www.jamamedia.org)
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