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 )
This newest trial puts subclavian definitively on top (N Engl J Med 2015; 373:1220-1229)
What do you think? Leave your thoughts in the comments below.
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Scott Weingart
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45 Comments on "Podcast 80 – Uhmmmm, Maybe Groin Lines Are Not So Bad with Paul Marik"
the irony leaves a metallic taste
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.
Preston, thanks for getting that quote in here, I love it and forgot to add it!
Minh, wait till the journal club before you start counting coup
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
agree! No easier line than US guided IJ.
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.
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.
As long as you are doing it full-sterile, I absolutely agree.
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)
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.
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.
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.
great story, my friend!
it’s called the “tertiary survey”
yes it is, that will be a great topic for a wee
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.
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??!
agree
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.
same practice as me for resus.
+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).
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
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:
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;-).
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.
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.
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.
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.
no data that i could find, but physiologically, I do worry about DVT increase with this approach.
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.
Frank,
Amazing technical tips!!!!
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.
I think most places understand there will be times when the femoral is the best choice.
[…] Uhmmmm, Maybe Groin Lines Are Not So Bad with Paul Marik aka the great debate between two great minds of EMCC. Think this sums it up well “The femoral route is for acute resuscitation, then the line comes out upon transfer to the receiving unit.” […]