Vascular access sites for acute renal replacement in intensive care units

Abstract

Background and objectives: Several temporary venous catheterizations are sometimes required for acute renal replacement therapy (RRT) in the intensive care unit (ICU). This study compares first and second catheterizations in the femoral and jugular veins in terms of patient safety.

Design, setting, participants, & measurements: A crossover study from the catheter-dialysis randomized study (Cathedia), which was conducted among 736 critically ill adults requiring RRT, was performed. Catheter insertion complications, catheter-tip colonization, catheter dysfunction and urea reduction ratio (URR) were analyzed considering the crossover and longitudinal designs.

Results: This study analyzed 134 patients who underwent two different sites of catheterization, 57 and 77 of whom were initially randomized in the femoral and jugular site, respectively. Using anatomic landmarks, time to insert a femoral catheter was shorter (P=0.01) and more successful (P=0.003) compared with catheterization in the jugular site. Time to catheter-tip colonization at removal was not significantly different between the two sites of insertion (median, 14 days in both groups; hazard ratio, 0.99; 95% confidence interval, 0.61-1.59; P=0.96), as well as time to dysfunction. URRs were analyzed from 395 dialysis sessions (n=48 patients). No significant difference (P=0.49) in mean URR was detected between sessions performed through femoral (n=213; 50.9%) and jugular (n=182; 49.5%) dialysis catheters.

Conclusions: These results validate prior results of this study group and extend external validity to the second catheter used for RRT in the ICU. Femoral and internal jugular acute vascular access sites are both acceptable for RRT therapy in the ICU.

Figure 1.

Crossover patient flowchart.

Figure 2.

Kaplan-Meier curves, comparing the two vascular access routes (femoral in blue shape and jugular in red shape), related hazard ratio, 95% confidence interval, and P value of the log rank test, using the “sandwich” robust estimator of the variance, considering the crossover design. (A) Time to catheter colonization estimation. (B) Time to dysfunction estimation.

Figure 3.

Histograms of the urea reduction ratio (URR) of dialysis. (Left) Under a femoral catheterization. (Right) Under a jugular catheterization. The result of the linear mixed model comparing the mean URR, depending on the access route, is also presented.