Femoral vs Jugular Venous Catheterization and Risk of Infection
Abstract & Commentary
By Dean L. Winslow, MD, FACP, FIDSA Chief, Division of AIDS Medicine, Santa Clara Valley Medical Center; Clinical Professor, Stanford University School of Medicine Dr. Winslow serves as a consultant for Siemens Diagnostics, and is on the speaker's bureau for Boehringer-Ingelheim and GSK. This article originally appeared in the August 2008 issue of Infectious Disease Alert. It was edited by Stan Deresinski, MD, FACP, and peer reviewed by Connie Price, MD. Dr. Deresinski is Clinical Professor of Medicine, Stanford University; Associate Chief of Infectious Diseases, Santa Clara Valley Medical Center, and Dr. Price is Assistant Professor, University of Colorado School of Medicine. Dr. Deresinski is on the speaker's bureau for Merck, Pharmacia, GlaxoSmithKline, Pfizer, Bayer, and Wyeth, and does research for Merck. Dr. Price reports no financial relationships relevant to this field of study.
Synopsis: In this study, 750 severely ill patients requiring initial hemodialysis were randomized to receive either jugular or femoral vein catheterization. Jugular catheterization significantly increased the incidence of catheter colonization in patients with body mass index (BMI) < 24.2, whereas jugular catheterization decreased the incidence in patients with BMI > 28.4. Across all BMI strata, there was no significant difference in catheter-related blood stream infections in patients who underwent femoral vs jugular catheterization.
Source: Parienti JJ, 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;299:2413-2422.
In france, 750 patients from 12 hospitals participated in a concealed, randomized, multicenter, evaluator-blinded, parallel-group trial (the Cathedia study) conducted between 2004 and 2007. Severely ill, bed-bound adults with BMI < 45, who required first catheter insertion for renal replacement therapy, (RRT) were enrolled and randomized to femoral vs internal jugular (IJ) access. Morbidly obese patients with BMI > 45, local skin infection, volume overload precluding Trendelenburg position, presence of an AV fistula, thoracic contraindications, and those patients with only one site available were excluded. All operators were experienced, and employed appropriate sterile technique at both sites. Seldinger technique was used at both sites. Ultrasound guidance was recommended for IJ insertion, but was not required. Catheter colonization was defined as catheter tip culture with > 103 CFU/mL. Catheter-related bloodstream infection was defined as catheter tip colonization plus at least one peripheral blood culture yielding the same organism within 48 hours of catheter removal.
Jugular catheters were more difficult to insert and required longer insertion times, and insertion resulted in more failures on one side and more crossovers to the femoral site and more hematomas. Two patients in the jugular group had severe respiratory distress due to compressive hematoma; they required intubation.
The overall incidence of catheter colonization was similar between the femoral vs jugular groups (40.8 vs 35.7/1000 catheter-days). Colonization of the catheter with Gram-positive organisms (mostly Staphylococcus epidermidis) was seen in 41 femoral vs 51 jugular catheterizations and Gram-negative organisms in 30 femoral vs 15 jugular catheterizations. Catheter-related BSI incidence was 1.5/1000 catheter days in the femoral vs 2.3/1000 in the jugular group, but this difference was not statistically significant. Subgroup analysis was remarkable for significant differences in catheter colonization incidence by BMI tercile. Patients in the lowest BMI tercile (< 24.2) experienced catheter colonization incidence of 23.7/1000 catheter days with femoral catheters vs 45.4/1000 with jugular catheters (HR 2.10). Patients in the highest BMI tercile (> 28.4) experienced catheter colonization incidence of 50.9/1000 by femoral vs 24.5/1000 by jugular route (HR 0.40).
It has been axiomatic since I began training in the early 1970s that the femoral site should be avoided in all adults for venous catheter insertion due to the perceived increased risk of BSI associated with the femoral route; either the IJ or subclavian sites were favored. However a critical look at the literature suggests that this perception had largely been based on anecdotal data. This important study shows fairly conclusively that in patients with normal or low BMI that the risk of catheter colonization and infection is greater with IJ vs femoral site catheterization. Only in obese patients was catheter colonization increased with femoral vs IJ catheterization. This study does not address the relative rate of catheter colonization and BSI in subclavian vein catheterization, which may be superior to both the femoral and IJ sites. The increased risks of vascular complications associated with IJ insertion (and of both iatrogenic pneumothorax and vascular complications associated with subclavian insertion) need to be considered as well. These data suggest that, except in very obese patients, the femoral site may be appropriate for venous access, when necessary, especially when the expected duration of catheter placement at the femoral site is likely to be short term.