Podcast 80 – Uhmmmm, Maybe Groin Lines Are Not So Bad with Paul Marik

When I read a recent meta-analysis by Paul Marik, the first thing I did was bang my head against the wall 10 or 20 times. For seven years I have been trying to get people to put in neck lines because we KNOW the infection and DVT risk is lower, right? Well Dr. Marik’s review may significantly lower our certainty. You remember Paul Marik; he was on the show discussing fluid responsiveness a few months ago. He is a Professor and Division Chief of Pulmonary Critical Care at Eastern Virginia Medical Center.

Well, let’s get to the actual meta-analysis on femoral central lines first…

The Meta-Analysis

Marik, Flemmer, 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 Aug;40(8):2479-85.

Some of the Component Articles

Nagashima 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 Dec;12(6):363-5.

Lorente et al. Central venous catheter-related infection in a prospective and observational study of 2,595 catheters. Crit Care. 2005; 9(6): R631–R635.

The Two Studies from Wales by Harrision et al.: 2009 data, 2010 data

The Plots

Femoral vs. Subclavian

Femoral vs. IJ

What to make of all this?

I believe the data from this meta-analysis still show that neck lines have less infection risk than groin. But what this article does establish quite a bit of doubt on this answer. I think this will allow for further trials, though the numbers will have to be large and the study well done. ANZICS can you help us please???

Update:

This trial looked at IJ vs. femoral by using data from 2 RCTs of biopatchs. Up until the 5 day mark, no difference between the two sites. ( American Journal of Respiratory and Critical Care Medicine 2013;188: Jugular versus Femoral Short-Term Catheterization and Risk of Infection in Intensive Care Unit Patients. Causal Analysis of Two Randomized Trials )

What do you think? Leave your thoughts in the comments below.

Now on to the Podcast:

 

 

 

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Comments

  1. Minh Le Cong says:

    the irony leaves a metallic taste

    • preston wigfall says:

      Meta-Analysis is to analysis as Meta-physics is to physics. Interesting but it won’t enable you to send a rocket to the moon (but you will be able to reason that the moon is there.) Common sense does inform one that the risk of infection might be higher in an area close to where urine and feces play. I do agree that the bias against femoral lines is not IA.

    • Minh, wait till the journal club before you start counting coup

  2. Scott,
    I work in the same demograph as Minh – and I disagree with the femoral route.
    The majority of my sick patients are obese, diabetic with dodgy beans.
    3 reasons not to put fem lines in here:
    (1)obese = yuck, almost always have Candida on inspection,
    (2) immunocompromised and
    (3) they are sick enough that I am sending them out for ICU + likely some acute renal replacement – so I do not want to burn one of their femorals if the ICU team need it later.

    On a completely subjective note: IJ is easier I think in the post-US era. I struggle with femoral insertion in the fat folks – it is deep and too many things go wrong when I fiddle down there.
    Casey

  3. While I do agree that Femoral route is a high risk procedure. It is a skill that should be reserved for life saving interventions in patients with difficult or unavailable venous access. It is important to remember that not only does it require very little training but that it also has fewer risk outside of infection if performed properly than does IJ or Subclavian.
    It is certainly not something I would recommend for the ICU setting where time and resource abundance lies, yet it may retain its place in the emergent ED patient and possibly properly trained (aseptic) pre-hospital personnel. It’s ease of placement and efficiency makes it a great alternative in the moments when seconds matter.

  4. Although I generally support protocols, standardization of care, guidelines, etc, sometimes I think we try too hard to “make” certain things work for individual situations. In most patients I will try to put in an IJ or subclavian in, but there are certainly situations where the circumstances of my patient favors a femoral line. Usually the risks/benefits of those specific circumstances will greatly outweigh whatever infection difference there is in line site (the very fact that there is still argument suggests the difference is small). Studies like this sometimes make me feel “liberated” – I can do the right thing for my patient without someone nitpicking things like line site.

  5. Seth Trueger says:

    great podcast & discussion! I agree with you that while this makes the femoral line more palatable, there are still a lot of complications at the fem site (eg RP bleed) that make it less favorable. And if Bret Nelson taught me anything (he taught me many things) it’s that the femoral anatomy is not nearly reliable enough for landmarks & US is really important.

    I see Marik’s paper like the transfusion goals Manny Rivers used — since we started collecting data on CLABIs & DVTs, we also started using full sterile & widespread DVT prophylaxis, just as the data around transfusion goals changed around the same time EGDT began. So clean lines are probably all similarly clean, and if anything, this is another reason for the crash line to NOT be a fem line (in addition to the collapsing vein in hypotension, and pulsatile vein in CPR)

  6. Jimmy D says:

    The femoral route is for acute resuscitation, then the line comes out upon transfer to the receiving unit.

    As a side note, I learned something interesting while staffing a medical mission to Columbia (the state hospital of Santander with the Milwaukee Medical Mission–plastic surgery and urology cases). The local academic anesthesiologists shared with me that they do not place internal jugular lines–they exclusively use the subclavian route due to the high rate of central line infections with the IJ route. It all boils down to the distance from skin to vein–subclavian catheters are essentially “tunneled” compared to other lines due to the distance travelled through sub cut/fat/other tissues before entering the vein. It was warm enough in that hospital that I didn’t see a single blood warmer or active measures at warming their patients. And there was a huge hive of some type or beatles outside the OR window.

    • The femoral route is for acute resuscitation, then the line comes out upon transfer to the receiving unit.

      Exactly!!!

      • Perhaps the IO is for acute resuscitation, rather than the Femoral line. The Fem CVC takes longer and has the wrong physical characteristics for fast flow; ie. long and narrow. If there’s time to do a Femoral line, there’s ttime to do an IJ or SC and then it’s about reasons to chose one site over another (coagulopathy, lung compromise, cervical collar, etc).

        However, if there’s no IO and CV access is the only option, I’d suggest using a vascath rather than a CVC.

        And U/S wins every time over landmark.

        • Yeah, talk of CVCs for resus leaves me puzzled.
          Better off with a RICC line or Swan sheath if you want to resuscitate with fluids fast.
          Chris

          • Matt & Chris,
            In the States, we include the sheathes (we call them cordis in Kleenex fashion) when talking about CVCs. If patient needed volume or products, they get a sheath. So when the Americans are talking about the femoral route for a crashing patient they are not talking about a small lumen triple cath, they are talking about the big boys. I have found the IO to be garbage for rapid infusion, love it for crashing patient that needs pressors or other stat drugs. Now the RICC is best of all and I wish it penetrated into more EDs.

  7. the infection numbers seem so small that it seems to me we should prioritorize and fire up about others issues that actually make a difference…there’s plenty of these where I work–like what treatment you run through the line.

    • Jimmy D says:

      CVC infection is now a condition that major insurers (i.e., Medicare) are using for DENIAL of payment to institutions. The sign on the wall of the doctors’ lounge here reads…”Was the CVC infection present BEFORE ADMISSION?” for good reason.

      Our health care systems cannot afford certain slip-ups, for example, allowing patients to fall out of bed and fracture their hips, CVC infections, and the like.

      Now, a story.

      During the last week of my internship, I spent 3 months on the trauma service in a hospital serving the south side of Chicago. I received a page around 1 AM about a patient that spiked a fever. 7 days or less left in my internship before I went into anesthesia–I had a choice: stay in bed and Rx Tylenol, or see the patient. I went to see the patient. I walked into this patient’s room, took one look at him and decided to examine him myself. Parked in his right femoral vein was a 9 fr introducer placed earlier that day in the ED (possibly by yours truly). Removal of the introducer also resulted in removal of the fever without any oral Tylenol administered whatsoever.

      We should just make this an automatic review of systems post-trauma bay admission.

    • Actually not that small. 8.6 per 1000 line days…If you imagine average ICU with 20 beds, if all patients have a line then that means 1 line infection every ~5 days in that ICU.

  8. Valerio P.B. says:

    In the ED femoral line can be a fast and easy backup IV line…but when the patient is stabilized, the adrenaline is went away i’m agree to change it by 24 hours…inserting a neck line with ecoguide is fast and with a very small risk so why not to do it??!

  9. I don’t have a problem with throwing in a femoral line as a crash line if I can’t get to the subclavian area for some reason. I did plenty of them as a resident.

    However, in the day and age of rapid access interosseous lines, why bother? I can get an IO into the patient in less time than anyone can get any kind of central line. Now I’ve got a good resuscitation line and I can stabilize the patient. Once the patient is stable, I’m starting the IJ or Supraclavicular line.

  10. RustedFox says:

    +1 for “IO for ease, then IJ for the win”.

    At my new job (a smaller shop in a medium sized city that’s beginning to see some real acuity), I had a guy circling the drain come in and asked nursing to grab the ultrasound. After first responding with … “uh… the… ultra… yeah, I’d have to go GET that”, they then looked at me like I was performing alien necromancy when I popped in the US-guided IJ. Then… wow, were they happy to have a reliable line. Now, they get my US whenever I want it. Pronto. :)

    (Note: the US machine is not kept in the department itself, but requires a thirty yard walk to the adjacent rads dept to grab).

  11. Scott,

    Following yourreply to Chris & I above(There was no Reply button under your comment) …

    Aha! This explains why an American vodcast demonstrating US guided IJ CVC insertion appered to be insertinga Swan-Ganz sheth. It makes more sense now

  12. How about those instances when the patient has a beautiful and thick external jugular. Anyone, tried passing a 9f to the SVC, or even a pacer wire to the RV in a real pinch?

    • I have placed a dozen or so central lines via EJ in pts who are coagulopathic. Few things to understand:

      • The EJ actually feeds into the subclavian, then the innominate. So it is a curvy path and the wire often gets hung up
      • there are valves that make wire passage a bit tougher, and worse wire withdrawal difficult at times
  13. Will Jewell says:

    Some great comments here but it all boils down to horses for courses ! What your experienced at , what the lines for , and although we don’t like to mention it how much care is taken with technique and asepsis , including post insertion care . In general nursing staff very good at aseptic use doctors not quite so good.
    There are so many factors that will influence the chance of a line getting infected and the diagnosis of a line infection that a meta analysis must be very hard to interpret. Technique ,puncture sites, clippers vs razors,catheter type , aseptic technique,dressings,aseptic use of line for injections and fluid use etc etc. as in a lot of medical practice it is as much about ” it ain’t what you do it’s the way that you do it ” must be a song in that somewhere;-).

  14. As a frequent patient in icu and hdu’s of my local hospital i have always found if upon admission theyve managed to put a neck line in i have not got a line infection during or just post admission. If however theyve used femoral lines i have always bar one admission received an infection of which over 50% of these have been severe enough to be classed as life threatening. I have had over 20 femoral lines over the course of many yrs. 3 of these infections left me fighting for my life critically ill. I personally would avoid femoral lines at all costs-prefering the standard neck line as i do find these lines are:
    A- less likely to be forgotten about by nurses so daily cleaning of site and surrounding area is not forgotten about and is methodically done.
    B- there are generally far fewer nasty bacteria surrounding someones neck than their groin. This is especially the case in those like myself who are both catheterised and foecally incontenent. Its difficult to keep a femoral line clean when not wearing nappy pads its mads much harder when you are.
    C- i feel some nurses believe femoral lines are surrounded by that much more bacteria they are not required to take as careful procautions as they would with any other central line in neck etc. This was similar when i had my picc lines as the nurse on two occassions said it was only the same as any other cannula and ahs didnt need to treat it differently in any way. I then refused to have this nurse administer my medication and was referred to as a ‘problem patient’ i am not a problem patient just one who has had several line infections due in part to either poor hand hygeine of nursing staff looking after me, poor knowledge of the bacterial risks of certain lines OR a combination of all factors. Either way i resent being referred to as a problem patient for asking the nursing staff to wash their hands is that not my right and why should i feel scared to offend them by asking this it is after all me who will end up with any infections cauaed by their poor hand hygeine….

    • Kitty, Thanks so much for those firsthand comments! Sounds like if you are in a hospital where situations like A,B, & C arise infection in the femoral route is much more likely. I think what you describe is the situation at most hospitals. I am sticking with the neck.

  15. Scott,

    First let me say I LOVE EMCRIT!!!! You and your site have had a profound impact on my practice, so thank you!
    I was on my way home from work and wanted to listen to episodes that I have missed and I came across episode 80 where you discuss central lines with Dr. Merrick. I wanted to bring one particular item up which I do not believe that you addressed when discussing central lines.

    Simply put the main purpose for central line is to give the clinician ready access to large vessels so they can rapidly fluid resuscitate the patients and give multiple medications including inotropes and vasopressors.

    Since Dr. Merrick’s study on central venous pressure put the “nail in the coffin” for the CVP I have found in my practice that there is very little use for central lines in the immediate resuscitation phase. What I have began doing is using the interosseous route. More specifically the product that I use is Vidacare’s EZ-IO. The EZ-IO allows me to draw any lab including blood cultures and lactate additionally I can put large volumes of fluid, blood, inotropes, and vasopressors through the interosseous route and have yet to have one single adverse event.

    Additionally, for all of the EZ-IOs that have been placed in the United States since the company’s inception there has been three documented infections. One should note that these three infections were most likely due to the fact that the EZ-IO was left in place longer than the manufacturer suggests.

    My question to you is have you ever used the EZ-IO and what experiences negative or positive have you had with the product?

    In my humble opinion, without the need for central venous pressure the most immediate and safest route during the resuscitation phase of the patient’s illness should almost always be the interosseous route. When speed matters I grab the drill!

    I look forward to your reply best wishes in the new year.

    • FlyinRN, Would you mid adding your name to any posts rather than just moniker. Also, when mentioning products it is best to mention whether or not there is any conflict of interest with the product. I think EZIO is the best rescue device for when you can’t establish an IV. I don’t see them as replacing central lines for pretty much any use.

  16. Matthias Barden says:

    This is tangentially related, but the closest post I could find…
    Last shift I had an IM resident yell at me for not putting a biopatch on an Art-Line. He told me it was hospital policy but then couldn’t find that policy. In the past my SICU attendings had specificly said not to use them on art-lines because they don’t see infections in these lines. My ER attendings had no opinion either way. What’s your practice, and is there any literature you’ve seen? Thanks!
    Matt Barden EM2

    • we don’t use them on a-lines. The big take-away is the second someone quotes a policy as justification, I stop the conversation until they produce said policy. To argue in any other fashion is a waste of your time.

  17. Robert Bonnin says:

    I am probably a little late to get a response, but I have recently being placing large bore central lines 10 -20 cm down the thigh using ultrasound to avoid the most bacterially contaminated areas, just as a short term resuscitation line. I find a site were the vein is superficial to artery and nerve as the insertion site or alternatively I tunnel through soft tissues and enter the vein in the distal femoral triangle. This should reduce infection but I am not sure if it would increase DVT rates. I would be interested in any comments.

  18. Forgive the short autobiographical comments, but designed to provide some ‘cred’ within the Emcrit community. I started my medical career as a Vietnam-era Special Forces & Ranger Medical Specialist, and our principal crash resuscitation access technique of those years were emergency surgical putdowns. I am currently an Interventional/Invasive Cardiologist of 20(+) years practice, a Boarded and practicing Intensivist of 24(+) years practice, and a practicing Emergency Medicine Physician with over 29,000 hours of ED practice of which 75% was logged while a military physician, including a combat tour as the Chief of Emergency Medicine in a Combat Support Hospital.

    Given my cardiology practice, the scope of which includes Cardiac Device Implantation (pacers and ICD’s) as well as diagnostic and interventional right and left heart catheterizations, my ICU practice which includes about 40% sepsis/septic shock patients, and my ED practice, I conservatively estimate I have accessed the central venous system (External Jugular, internal jugular, infraclavicular subclavian, supraclavicular subclavian, extra-thoracic axillary vein, fermoral venous, external iliac vein to common iliac vein (used for cardiac device implantation due to bilateral subclavian and axillary vein stenosis) in over 20,000 unique patients.

    The EmCrit community conversation on this topic while excellent has features which replicate intellectually the lethal knife-gun debate in the Magnificant Seven (see my blog page to re-visit this scene if not recalled or never seen before (http://statisticalmedievalist.blogspot.com/).

    In any case, the points I want to make are that extolling a single access methodology as the sole-source solution to a clinical problem is naive and as my daddy used to tell me, ‘use the right tool for the job, don’t use a single tool for all jobs.’

    As I know the community understands, the U/S guided IJ cannulation technique while a great advance has predictable issues with emergency line placement :
    1. It adds a non trivial time extension to the procedure.
    2. It entails significant risk of inadvertent carotid artery puncture in the patient who is under volume resuscitated with poor venous distention even in the setting of extreme Trendelenburg position when the vein lies directly overlying the carotid artery through the arteries course through the sternocleidomastoid triangle.
    3. In the setting of known coagulopathy the IJ route is poorly compressible, and I have seen at least 3 patients develop airway compromise from neck hematoma.
    4. Patient cooperation during a ‘crash’ vascular access situation, especially with a marginal airway can be dangerously compromising once the drape goes over the patient’s head.
    5. If CP arrest should ensue during preparation for the line, or worse during the line attempt, placing the line while attempting to maintain cardio-cerebral perfusion with good quality CPR is in my view a crap shoot worthy of your favorite Las Vegas Casino.
    6. Pain inputs from neck vein placement and subclavian vein placement far exceeds that occurring from an expertly done femoral line.
    7.EZ- I/O route while technically simple, fails to address the issues associated with requirements for high volume infusion in adults, multiple access requirements driven by IV drip incompatibilities, physical stability of line access during nursing care or transport positioning of the patient.
    8. Femoral dialysis catheters in my experience clearly outperform IJ catheters with respect to predictability of the adequacy of the 1st dialysis run, i.e., they have a lower fiddle factor than the IJ route, and as your readers may know the SC dialysis route is complicated at least 25% of the time with SC vein stenosis.
    9. I have experienced several cases of aeroembolism using IJ and SC routes in patients with high TV, high frequency respiration in spite of Trendelenburg positions (the position itself often precipitates or aggravates the situation it is trying to mitigate, the risk of devastating massive aero-embolism is nearly totally absent in the femoral route.

    While my own practice mirrors that of some of your contributors, i.e., emergency placement of the femoral line with prompt removal after the patient is stabilized and transition to a SC line or PICC line, there have been significant numbers of patients who required long term femoral line placement due to abnormal venous occlusive disease (such as SVC syndrome) or long standing chronic venous thrombotic disease that I was unable technically or due to severe renal dysfunction unwilling to attempt to reconstruct with cath revascularization techniques, or they had persistant coagulopathy again making neck and chest wall access unduly hazardous. I have never personally seen a line infection in these patients with prolonged femoral access driven by these unique clinical considerations. Certainly I have seen more SBE related to PICC line use than I have ever seen with central line placements, with many of those lines dating to an era when the PICC routes were yet to be under the operational control of the hospital nursing PICC teams.

    The reality is that line selection is a complex clinical judgement resistant to a ‘one size fits all’ strategy. It is driven by setting (level of hemodynamic instability, risks for abrupt ‘crash’), patient factors (anxiety, cooperativeness, sedation levels or safety for sedation, airway sustainability/adequacy/patency), operator experience and flexibility, and probable need for multiple drug infusions and therapies or likelihoood for emergency temporary dialysis support.

    I am not surprised that this meta-analytic literature review maps to my clinical instincts concerning the femoral access route. It is a welcome addition to my armamentarium since many non-clinicians (who ironically now ‘grade us’ for our core measure report cards) are doctrinaire and insensitive to the true and necessary complexity of line site selection.

    In summary, limiting yourself to a single tool, single access strategy is short sighted and can potentially result in your loss of a salvageable patient if you had more than one or tools in your toolbox.

    • Wonderful comment and I think most here would agree with you. Keeping all options in your back pocket is the mark of an experienced doc. Only thing I would comment on is that if placing a non-ultrasound guided line in a coagulopathic patient, I would still strongly recommend the IJ. As you allude to, the worst that will happen with a neck hematoma from IJ is the need for intubation. We have unfortunately seen exsanguinating retro-p bleeds from femoral site.

      • Sorry for my tardy response. I agree with you that there is great potential for hazard if you misplace the FV above the inguinal ligament. Due to the thousands of femoral vein access procedures I did in the cath lab with the luxury and valuable training from visually marking the target zone for the artery and venous access points with reference to determining the point by anatomical landmarks and then marking the proposed arterial entry site with a hemostat and then doing fluroscopy to verify the entry point, before making the entry to the artery and the vein, you become very comfortable with the target entry points for blind puncture of the femoral vein, and as a consequence build the ‘feeling’ for being below the inguinal ligament when doing the venous puncture. Thus in my own relatively unique case, I prefer the femoral route for rapid blind central access in the coagulopathic patient as I know the landmarks in this area cold.

        An additional technical note for the femoral route.

        Once you define the true course of the inguinal ligament, i.e., runs from the anterior superior iliac spine of the pelvis directly to the symphysis pubis, which in many if not most patients, but importantly not all, runs roughly overlying the inguinal crease (and I urge your readers to mark the course of the inguinal ligament by defining these two points by reference to palpation rather than rely on the course of the inguinal crease, which can throw you off, although generally by having you access the vein &/or the artery too low rather than too high) than I would recommend you use a technique taught to me by my Electrophysiology Mentor, who spent most of his day accessing the femoral venous circulation.

        The classical technique as you know is to address the vein about 1 cm below the point you would address the artery and go parallel to the femoral artery pulse about 1 cm medial. However, I was taught to enter the skin about 1 cm below the palpated femoral arterial pulse and 1 1/2 to 2-cm medial to the pulse than instead of keeping parallel to the artery, I direct the needle tip directly towards the femoral pulse keeping the needle at about 60 degrees to the perpendicular. The femoral vein runs deep to the artery generally being found lying just above the level of the femoral head about 1/2 to 1 cm deep to the femoral artery.

        And just as I learned when I was an Air Traffic Control Officer while in the USAF, or you learned when you drove a car, if you make your turn directly into the airplane/car as they are nose abreast, the one airplane or car travels behind the other. Similarly, since in the target area of femoral access, the femoral head, the area of compressibility, the femoral vein and artery lie directly next to each other, but as I say the femoral vein in most cases deep to the artery, pointing at the artery but consciously going deep (i.e., 60 to 70 degrees rather than 45 degrees) & wide from the pulse 2-cm results in a 1st pass access rate of >90-95%, since you are pointing to a landmark you can palpate during the veno-puncture attempt.

        Initially using this technique feels scary, as in particular you don’t necessarily want arterial access, but I am always willing to place a serendipitous arterial monitoring line in a shocky patient in the few cases where I enter the artery by this approach rather than the vein. But the 1st pass placement rate with this technique in my personal experience is so much higher than it was with the parallel access method, I never use the parallel approach.

        Finally, while U/S guidance is terrific, there is a time overhead which is difficult to justify in a code or a severely shocky patient which makes it less attractive in this setting. However, for routine non-crash central access, clearly U/S is the way to go and the standard of care.

  19. Simon Clausen says:

    I prefer the U/S guided IJ line in the vast majority of my patients because it is the easiest. I like to see where I am putting things which is more difficult with a subclavian line though I know some are experimenting with U/S guidance. That being said, I’ve had two patients recently with dyspnea that could not lie flat and certainly could not lie in Trendelenburg. Viewing the IJ under U/S showed a highly mobile deep vein that swung wildly with every dyspneic breath. I don’t like trying to hit a mobile target in a patient’s neck. The femoral line sufficed in these situations. The indication for the line in both cases was simply an inability to find any peripheral veins rather that a rapidly crashing patient. Unfortunately due to the extreme prejudice against this access point, people are afraid they’ll lose their medical license if they use it.

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