Original Investigation
Dialysis
Initial and Extended Use of Femoral Versus Nonfemoral Double-Lumen Vascular Catheters and Catheter-Related Infection During Continuous Renal Replacement Therapy

https://doi.org/10.1053/j.ajkd.2014.04.022Get rights and content

Background

The risk of catheter-related infection or bacteremia, with initial and extended use of femoral versus nonfemoral sites for double-lumen vascular catheters (DLVCs) during continuous renal replacement therapy (CRRT), is unclear.

Study Design

Retrospective observational cohort study.

Setting & Participants

Critically ill patients on CRRT in a combined intensive care unit of a tertiary institution.

Factor

Femoral versus nonfemoral venous DLVC placement.

Outcomes

Catheter-related colonization (CRCOL) and bloodstream infection (CRBSI).

Measurements

CRCOL/CRBSI rates expressed per 1,000 catheter-days.

Results

We studied 458 patients (median age, 65 years; 60% males) and 647 DLVCs. Of 405 single-site only DLVC users, 82% versus 18% received exclusively 419 femoral versus 82 jugular or subclavian DLVCs, respectively. The corresponding DLVC indwelling duration was 6 ± 4 versus 7 ± 5 days (P = 0.03). Corresponding CRCOL and CRBSI rates (per 1,000 catheter-days) were 9.7 versus 8.8 events (P = 0.8) and 1.2 versus 3.5 events (P = 0.3), respectively. Overall, 96 patients with extended CRRT received femoral-site insertion first with subsequent site change, including 53 femoral guidewire exchanges, 53 new femoral venipunctures, and 47 new jugular/subclavian sites. CRCOL and CRBSI rates were similar for all such approaches (P = 0.7 and P = 0.9, respectively). On multivariate analysis, CRCOL risk was higher in patients older than 65 years and weighing >90 kg (ORs of 2.1 and 2.2, respectively; P < 0.05). This association between higher weight and greater CRCOL risk was significant for femoral DLVCs, but not for nonfemoral sites. Other covariates, including initial or specific DLVC site, guidewire exchange versus new venipuncture, and primary versus secondary DLVC placement, did not significantly affect CRCOL rates.

Limitations

Nonrandomized retrospective design and single-center evaluation.

Conclusions

CRCOL and CRBSI rates in patients on CRRT are low and not influenced significantly by initial or serial femoral catheterizations with guidewire exchange or new venipuncture. CRCOL risk is higher in older and heavier patients, the latter especially so with femoral sites.

Section snippets

Study Design and Setting

We performed a single-center observational study of critically ill patients in a combined medical, surgical, and cardiothoracic ICU in a tertiary institution from December 2005 through June 2011. The Human Research Ethics Committee approved the study (H2011/04482) and waived the need for informed consent because it involved no intervention and data were de-identified and made anonymous.

Participants

All patients older than 16 years who underwent femoral and/or nonfemoral venous DLVC placement were included.

Participants and Descriptive Data

We studied 458 patients and 647 DLVCs (Fig 1). Median age and weight for all patients were 65 (interquartile range [IQR], 52-74) years and 75 (IQR, 65-90) kg, respectively. Median CRRT duration was 73 (IQR, 31-154) hours (Table 1). Of 501 femoral and 146 nonfemoral DLVCs, 227 (45%) and 67 (46%) had tip cultures performed, respectively (P = 0.9). A total of 108 of 647 (17%) DLVCs were removed after ICU discharge, within 2 (IQR, 1-4) days of ward transfer. Forty percent of these 108 catheters

Discussion

We demonstrated similar CRCOL and CRBSI rates in critically ill patients on CRRT regardless of initial DLVC site approach, specifically femoral versus nonfemoral sites. Consecutive femoral DLVC placement (guidewire exchange or new venipuncture) for extended CRRT did not significantly increase infection risk compared with change to nonfemoral sites. Secondary versus primary DLVC placement was associated with higher CRBSI risk, an effect likely dependent on longer ICU stay. Older and heavier

Acknowledgements

Support: None.

Financial Disclosure: The authors declare that they have no relevant financial interests.

Contributions: Research idea and study design: HRC, RB, AGS, NS; data acquisition: HRC, RB, AGS, NS, NL, MC, JG, GW, ML, CM, AC, MG; data analysis/interpretation: HRC, RB, AGS; statistical analysis: HRC; supervision and mentorship: RB; drafting of manuscript: HRC, RB. Each author contributed important intellectual content during manuscript revision and accepts accountability for the overall

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    Copyright © 2014 National Kidney Foundation, Inc. Published by Elsevier Inc. All rights reserved.