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Three Part Question

In [patients requiring central venous pressure monitoring] does the insertion of [a femoral central line as apposed to an internal jugular or subclavian line] increase the rate of [infective complications]

Clinical Scenario

You are attending to a 68 year old gentleman who was found in his car having left the road and hit a tree. On arrival his GCS was 6 and he had 2 fractured clavicles and an open fracture of the left humerus. His BP is 90/50 and his pulse is 110 and after stabilisation you call an anaesthetist to intubate him, with cervical collar in situ. While he is doing this, you find multiple medications for heart failure in his pockets and the radiographer brings you a large packet of his old films including several showing pulmonary oedema. There is nothing acute on his ECG and only mild cerebral oedema is seen on the head CT. You can see that his fluid balance will be very difficult to manage over the next few days and that the balance between hypovolaemia and pulmonary or cerebral oedema will be vital to management. You elect to insert a femoral central line but wonder if there will be any infective risks to placing this into the femoral vein rather than the currently inaccessible cervical region.

Search Strategy

Medline 1966-09/02 using the OVID interface
[(exp.femoral vein/ or femoral vein.mp ) AND (exp.catheterisation, central venous/ ) OR (exp. catheterisation/ or catheterisation.mp) AND ( exp sepsis/ OR sepsis.mp )]

Search Outcome

Out of 56 papers 6 were found to be relevant. These papers are shown in the table.

Relevant Paper(s)

Author, date and country	Patient group	Study type (level of evidence)	Outcomes	Key results	Study Weaknesses
Kanter et al 1986 USA	Phase 1: 3 year surveillance in paediatric ICU of 161 catheters (49 femoral) Phase 2 : 29 paediatric patients needing central line had femoral line. (1/3rd of all children studied were under 10kg)	Cohort study	Phase 1 complications	Femoral line:6.1% complication rate incl. 1 cellulitis. Neck sites:4.5% complication rate, incl. 1 sepsis N/S	Catheter tips not sent off for routine culture, only clinical infections measured Median time catheter was in place in phase 2 was only 3 days. Very small study to detect absence of infective risk in phase 2. No power calculations done to exclude type II error. 14% arterial puncture rate
			Phase 2 complications	No infective complications were found
Durbec et al 1997 France	80 consecutive patients undergoing femoral central line in a single adult ICU.	Observational Cohort study	Infective complications	Sepsis seen in 3 (4%) patients and catheter bacterial colonisation in 11 ( 14%) patients	No power study performed Uncontrolled study
Richet et al 1990 France	503 central catheters in 566 intensive care patients from 8 french centres. 308 internal jugular or subclavian lines and 69 femoral lines	Cohort study	Infective complications	No significant difference found between femoral and neck line insertion. Logistic regression found that infection was related to duration of catheterisation, use of semipermeable transparent dressing and internal jugular access site	This is a study that is mainly looking at peripheral vs central line infectious complications and therefore the data on femoral lines is poorly and incompletely presented. In addition it is likely that the study is underpowered to exclude femoral line as a risk factor. (no power calculations given)
Williams et al 1991 USA	123 mixed surgical and medical ICU patients	Prospective study	Infective complications	150 femoral catheters inserted with no catheter-related sepsis	This paper is in an ICU setting rather than in an emergency department, which is presumably a more controlled and sterile environment. No power calculations to prove that their null findings are significant.
			Other complications	9.3% arterial puncture4.7% local inflammation, 10% local bleeding
Timsit et al 1999 France	336 patients in 3 French Intensive care Units. Randomly assigned to tunnelled or non-tunneled femoral venous catheter. 10cm tunnel was used.	RCT	Infective complications	Non-tunneled femoral line sepsis 15 of 168 (8.9%). Tunneled femoral line sepsis 5 of 168 (2.9%) p=0.005. Tip culture and probable sepsis risks both also significantly higher for non-tunneled group. Tunnelling the line reduces septic complications by 4 times. NNT to prevent 1 infection is 17	92% were ventilated
			Time for insertion	15 mins for non-tunneled line and 25 mins for tunneled line
			Other	7 DVTs, 9 insertion failures and 25 arterial punctures
Merrer et al 2001 France	289 adult patients in 8 French Intensive Care Units receiving first central line. Randomly assigned to femoral insertion (N=145) or subclavian insertion (N=144) 93% of Catheter tips sent for culture	RCT	Infectious complications	Minor infections: Femoral 19.8%, Subclavian 4.5% P<0.001. Catheter Sepsis: Femoral 4.4%, Subclavian 1.5% P=0.07	Well conducted study Number needed to treat with subclavian rather than femoral line to prevent one infection is 7
			Other Femoral Vs Subclavian	Arterial puncture 13 pts vs 7 pts. Bleeding 7pts Vs 5 pts. Also 4 pneumothoraces with subclavian insertion.

Comment(s)

No studies were found for Central Lines inserted in the emergency department setting. All studies were conducted in the Intensive care unit and therefore their estimates of infection rates are likely to be underestimates for our own setting. Minor infection rates varied from 6.1% to 19.8%, and sepsis rates ranged from 0% to 8.9%. Merrer et al were the only study to demonstrate a significant difference in minor infection rates and no study demonstrated an increased sepsis rate using the femoral route. Timsit et al showed a significant reduction in the infection rate if tunnelling the femoral line was performed. Therefore it seems that there is little evidence of a prohibitively high infection risk using the femoral route and no evidence of an increased sepsis rate, although if both sites are available, the balance of evidence would suggest that the neck route should be preferred.

Clinical Bottom Line

There is little evidence that inserting a femoral central line increases the rate of infection, although the balance of evidence would suggest that cervical central lines should be the preferred procedure.

References

1. Kanter RK, Zimmerman JJ, Strauss RH, Stoeckel KA. Central venous catheter insertion by femoral vein: safety and effectiveness for the pediatric patient. Pediatrics 1986;77(6):842-7.
2. Durbec O, Viviand X, Potie F, Vialet R, Albanese J, Martin C. A prospective evaluation of the use of femoral venous catheters in critically ill adults. Crit Care Med 1997;25(12):1986-9.
3. Richet H, Hubert B, Nitemberg G, Andremont A, Buu-Hoi A, Ourbak P et al. Prospective multicenter study of vascular-catheter-related complications and risk factors for positive central-catheter cultures in intensive care unit patients. Journal of Clinical Microbiology 1990;28(11):2520-5.
4. Williams JF, Seneff MG, Friedman BC, McGrath BJ, Gregg R, Sunner J et al. Use of femoral venous catheters in critically ill adults: prospective study. Crit Care Med 1991;19(4):550-3.
5. Timsit JF, Bruneel F, Cheval C, Mamzer MF, Garrouste-Org, Wolff M et al. Use of tunneled femoral catheters to prevent catheter-related infection. A randomized, controlled trial. Ann Intern Med 1999;130(9):729-35.
6. Merrer J, De Jonghe B, Golliot F, Lefrant JY, Raffy B, Barre E et al. Complications of femoral and subclavian venous catheterization in critically ill patients: a randomized controlled trial. JAMA 286(6):700-7, 2001.