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Let´s focus today from the point of view of whom is lying opposite, facing up. Published in Critical Care in 2011, do echo of the article Early intra-intensive care unit psychological intervention promotes recovery from post traumatic stress disorders, anxiety and depression symptoms in critically ill patients.
The intervention of clinical psychologists from admission to ICU could help our patients to recover from stressful experience. A conclusion that seems obvious and that leads to ask... why psychologists are not a part of the team?. 30-60% of our patients suffer from this type of sequels, why not get them in value?.
As in other studies, the authors used questionnaires to assess levels of post-traumatic stress, anxiety and depression and quality of life (scale HADS, Impact of Event Scale-Revised, IES-R and Quality of life EQ5D questionnaire), and conducted an observational study with a control and intervention group. In the team there were three clinical psychologists, with a guaranteed daily presence from 12 to 16 p.m and available by phone during 24 hours, with an annual cost of 30,000 euros.
Anxiety and depression levels were lower in the intervention group, and the percentage of patients who needed psychiatric medication was significantly lower in the intervention group, as well as a 41.7% compared with a 8.1% to the year's high of UCI.
I would like to repeat: where are the psychologists?.
Slides are here:
Risk of catheter-related bloodstream infection in patients with femoral central venous catheters
What is the evidence regarding catheter-related bloodstream infections (CRBI) associated with central access using the femoral vein compared to other sites?
The Quick Answer:
There is no RCT evidence that femoral access has a higher rate of CRBI compared to other sites, although there is some evidence that catheter colonization occurs at a higher rate in femoral lines.
The Longer Answer
Why are we interested in this question/brief introduction?
CDC guidelines recommend avoiding the femoral vein for central lines due to increased infection rates.1 This is referred to as level 1a evidence, but a 2012 systematic review disputed the recommendation, concluding that there is no level 1a evidence and that recent studies show no significant difference in CRBI based on site.2
What is the evidence on this topic?
Only 2 RCTs have addressed this topic. One compared femoral and subclavian lines in 270 patients.3 There was a trend towards higher rates of ‘catheter-related clinical sepsis’ in the femoral group, but the difference did not reach statistical significance. CRBI occurred in 6 of 134 (4.4%) patients with femoral lines versus 2 of 136 (1.5%) patients with subclavian access. However, femoral catheters were significantly more likely to be colonized than subclavian lines.
Another trial randomized 750 patients who required short term dialysis access to femoral versus internal jugular access.4 They found no significant differences in CRBI nor in catheter colonization. Subgroup analysis showed significantly increased colonization rates for patients in the femoral group who were within the highest tercile for BMI (> 28.4 kg/m2), which seems intuitive. Surprisingly though, the femoral site had a significantly lower rate of catheter colonization among patients in the lowest tercile for BMI (< 24.2 kg/m2).4 Although colonization by itself has no obvious clinical impact, it would be interesting to see if data from larger trials reflect these findings for CRBI rates.
In a 2012 systematic review and meta-analysis, Marik and colleagues2 included the two RCTs described above as well as 8 cohort studies.3-13 Overall, no significant difference in CRBI was identified comparing femoral to subclavian sites. However, the femoral site was significantly more likely to be associated with CRBI compared to internal jugular lines (risk ratio 1.90; p=0.005). Meta-regression showed a significant difference in femoral infection rate based on the year of publication, and the authors found 2 of the cohort studies to be outliers.10,11 When they excluded the data from the outliers, they found no difference between femoral and internal jugular CRBI.
A 2012 Cochrane Review had a similar conclusion,14 finding no significant differences between femoral and IJ lines regarding colonization nor CRBI – this is based on the study of hemodialysis patients mentioned above.4 They did recommend subclavian over femoral access based on increased rates of colonization, but they found no significant difference in CRBI between these two sites.14
What is the quality of evidence on this topic? Are there any limitations?
The evidence is limited, especially if using it to practice emergency medicine. The populations and comorbidities are quite different from the average ED patient requiring central access. The purpose for CVC placement and the setting in which it is inserted do not reflect our practice. Since the earliest of these studies was published, a shift towards “care bundles” has resulted in drastic decreases in infection rates,15 potentially affecting the relevance of earlier trials.
My Main Conclusions From the Literature Reviewed:
There is no strong evidence that femoral lines are associated with higher rates of CRBI. However, absence of evidence is not evidence of absence, and I am still skeptical that these lines carry no more risk than other sites. There are situations when femoral access is clearly preferable, for example when procedures are occurring near the neck, with ongoing CPR, or if a patient has a difficult time cooperating with a drape over their face; it seems perfectly reasonable to utilize the groin when IJ and subclavian access is limited. That being said, until there are better studies that assess a more representative patient population, I will avoid femoral access when possible.
If you read one paper on this topic, read this:
Marik et al. The risk of catheter-related bloodstream infection with femoral venous catheters as compared to subclavian and internal jugular venous catheters: a systematic review of the literature and meta-analysis. Crit Care Med. 2012; 40(8):2479-85.
Watch out for the Venous Site for Central Catheterization trial, an RCT currently enrolling patients to compare CRBI for subclavian, internal jugular, and femoral access. This French study intends to enroll over 3,000 ICU patients at multiple sites. Completion date is set for January 2015.
For more FOAMed resources on this topic, visit our friends at:
- O’Grady NP, et al: CDC Guidelines for the Prevention of intravascular catheter-related infections. Centers for Disease Control and Prevention. 2011. Accessed August 22, 2014.
- Marik PE, et al. The risk of catheter-related bloodstream infection with femoral venous catheters as compared to subclavian and internal jugular venous catheters: a systematic review of the literature and meta-analysis. Crit Care Med. 2012; 40(8):2479-85.
- Merrer J, et al. Complications of femoral and subclavian venous catheterization in critically ill patients: a randomized controlled trial. JAMA. 2001; 286(6):700-7.
- 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(20):2413-22.
- Deshpande KS, et al. The incidence of infectious complications of central venous catheters at the subclavian, internal jugular, and femoral sites in an intensive care unit population. Crit Care Med. 2005; 33(1):13-20.
- Garnacho-Montero J, et al. Risk factors and prognosis of catheter-related bloodstream infection in critically ill patients: a multicenter study. Intensive Care Med. 2008; 34(12):2185-93.
- Goetz AM, et al. Risk of infection due to central venous catheters: effect of site of placement and catheter type. Infect Control Hosp Epidemiol. 1998; 19(11):842-5.
- Gowardman JR, et al. Influence of insertion site on central venous catheter colonization and bloodstream infection rates. Intensive Care Med. 2008; 34(6):1038-45.
- LeMaster CH, et al. Infection and natural history of emergency department-placed central venous catheters. Ann Emerg Med. 2010; 56(5):492-7.
- Lorente L, et al. Central venous catheter-related infection in a prospective and observational study of 2,595 catheters. Crit Care. 2005; 9(6):R631-5.
- Nagashima G, et al. To reduce catheter-related bloodstream infections: is the subclavian route better than the jugular route for central venous catheterization? J Infect Chemother. 2006; 12(6):363-5.
- Welsh Healthcare Associate Infection Programme – critical care surveillance: central venous catheter related infections. 2008. Accessed August 22, 2014.
- Welsh Healthcare Associate Infection Programme – critical care annual report: central venous catheter and ventilator associated pneumonia. 2010. Accessed August 22, 2014
- Ge X, et al. Central venous access sites for the prevention of venous thrombosis, stenosis and infection. Cochrane Database Syst Rev. 2012; 3:CD004084.
- Blot K, et al. Prevention of Central Line-Associated Bloodstream Infections Through Quality Improvement Interventions: A Systematic Review and Meta-analysis. Clin Infect Dis. 2014. pii: ciu239. [Epub ahead of print]
Think about what you do in the ED? Do you recognize how the following studies have impacted your practice?
Multicenter, prospective, observational study of patients with blunt trauma for whom cervical spine X-rays were obtained.
Get C-spine films if:
- Patients with abnormal neurologic examination
- Distracting or painful injury (like a femur fracture)
- Depressed or altered mental status
- Midline cervical tenderness should get an X-Ray
A prospective cohort study in Canada evaluating patients with head or neck trauma.
Radiography in high risk factors
- Dangerous mechanism
Assess range of motion in low-risk factors. If ANY of the following are present AND the patient can actively rotate 45 degrees to left and right, then C-spine films may not be needed.
- Simple rear-end MVC
- Sitting position in the ED
- Ambulatory at any time since injury
- Delayed onset neck pain
- Absence of midline C-spine tenderness
Edit: Corrected Canadian C-spine rule to state if ANY of the above 5 items are present
As relieved as we are that the Ebola outbreak appears to be limited and less of a daily concern in our emergency departments, we do still remain on alert for the outbreak of other infectious diseases. It’s been very gratifying to see several ACEP members who are subject matter experts in infectious disease step up and help us create the resources we’ve posted on ACEP.org for the entire emergency medicine community. Among those experts are Kristi Koenig and Carl Schultz from the University of California at Irvine. They’re working on a new edition of their book on disaster medicine and realized that the chapter on emerging infectious diseases would be very useful to us all right now. As they said,
“The emergency health care system must be prepared for an evolving public health event of international significance such as this. Emergency physicians are on the front lines and should be knowledgeable, up-to-date, and ready to effectively manage infectious disease threats. It doesn’t matter whether such threats arise from Ebola virus disease, Enterovirus D-68, MERS-CoV, SARS, the 2009 H1N1 pandemic, or the next big event, as yet unnamed. We should be leaders in our hospitals, EMS systems, and communities, advocating for protection of the public health, our patients, and colleagues.”
Kristi and Carl have donated a preliminary electronic draft of that chapter to the College – to all of you, really – as a resource to help you and your team prepare to screen for and treat the wide range of infectious diseases any of us could see any day of the week.
Just follow this link to download the chapter now.
Best wishes to you all, and be well. We hope to see you next week in Chicago for ACEP14.
Alex M. Rosenau, DO, CEP, FACEP
Micahael J. Gerardi, MD, FAAP, FACEP