Journal Club: Keys to Access?
Parienti, Jean-Jacques, et al. “Intravascular Complications of Central Venous Catheterization by Insertion Site.” New England Journal of Medicine, vol. 373, no. 13, 2015, pp. 1220–1229., doi:10.1056/nejmoa1500964.
This is a randomized trial investigating the difference in complication rates between subclavian, jugular, and femoral central venous catheters placed in the ICU setting in nine French hospitals from December 2011 to June 2014. The primary outcome was a composite of central line-associated bloodstream infections (CLABSI) and symptomatic deep vein thrombosis. Secondary outcomes included time to catheter-tip colonization and time to total DVT after catheter removal, in addition to rate of major mechanical complications. Their findings of note were that subclavian catheters had less infection and symptomatic DVT rate than femoral and jugular catheters, but with the trade-off of more mechanical complications (pneumothorax).
Our Journal Club discussion focused on multiple points, including their randomization strategy, which allowed the investigators to effectively compare catheter site complications. The paper also used intention-to-treat (ITT) analysis and per protocol analysis, highlighting the value of ITT strategies to avoid false positives. The paper was funded both by the French Ministry of Health and a chlorhexidine manufacturing company, with evidence in the paper that there was bias of unclear significance introduced by receiving funding from a private company.
Overall, this paper appears to support the utility of subclavian venous catheters, and showed less difference than we expected between jugular and femoral venous catheters regarding cleanliness. Many of the residents therefore expressed interest in improving subclavian catheterization skills.
Chreiman, Kristen M., et al. “The Intraosseous Have It: A Prospective Observational Study of Vascular Access Success Rates in Patients in Extremis Using Video Review.” Journal of Trauma and Acute Care Surgery, vol. 84, no. 4, 2018, pp. 558–563., doi:10.1097/ta.0000000000001795.
This paper used video review of penetrating trauma patients undergoing ED thoracotomy in an urban Level 1 Trauma center to support the use of IO as a first line option for access. They found that IOs had a high success rate (>90%) and were just as fast as peripheral IVs and much faster than central line attempts. Our department’s senior nurses and residents are highly proficient at peripheral IV and crash central line placement, but the value of IO as a “something better than nothing” option is compelling. This paper’s finding supported many of our anecdotal experiences regarding speed and effectiveness with IO placement in critically ill patients. The ethical question of filming patient care was also a major point of conversation, with no clear consensus.
April Journal Club Discussion Leader: Jerome Hoke, MD (PGY-2) 2019-2020 Academic Year Journal Club Leaders: Sarah Balog, DO (PGY-3); Rose Solomon, MD (PGY-2); David Andonian, MD (Faculty Advisor)