Having an internal jugular (IJ) catheter with a concurrent tracheostomy did not increase the risk for central line–associated bloodstream infections (CLABSIs) among ICU patients.
“Our data challenges what seems to be the standard when placing lines in patients with tracheostomy,” said Dana L. Russell, MPH, the lead author of the single-center, retrospective, matched case-control study of more than 500 adult patients from five ICUs.
Researchers from the Department of Anesthesiology of the David Geffen School of Medicine at the University of California, Los Angeles, compared the risk for CLABSIs between ICU patients who had an IJ catheter with and without a tracheostomy. Findings were presented at the 2017 annual meeting of the Society of Critical Care Medicine (abstract 527).
The retrospective case-control study included adult ICU patients at Ronald Reagan UCLA Medical Center from March 2013 to December 2015. A case was defined as any patient with a CLABSI who had an IJ central line for more than two calendar days at the time of CLABSI onset (n=85).
“The lack of evidence to support the risk of infection that tracheostomy poses should be considered by practitioners when selecting a site for cannulation,” she said. “Our findings support the clinical decision-making process regarding site selection for line placement. The decision between the internal jugular versus femoral site for cannulation, for example, is not always so clear-cut. Data can help in this regard.”
The study found no association between IJ CLABSI and the presence of a tracheostomy, said Vivek K. Moitra, MD, the Allen I. Hyman Associate Professor of Critical Care Anesthesiology at Columbia University College of Physicians and Surgeons, in New York City. Calling the study thought-provoking, Dr. Moitra said it “enhances our understanding of how CLABSIs occur.”
In the study, CLABSIs were identified by ongoing routine surveillance using standard CDC definitions. Controls included all noninfected patients with IJ catheters in the same ICU on the date of CLABSI (n=976). The study’s authors said a conditional logistic regression model was constructed to estimate the relative risk (RR) ratio for different variables, including age, ICU length of stay, tracheostomy, number of lines, number of lumens, adherence to maximal sterile barrier precautions for line placement and line dwell times.
They showed that in the multivariate model, the risk for CLABSI did not increase in patients with IJ catheters and a tracheostomy compared with patients with IJ catheters alone (RR, 0.88; 95% CI, 0.44-1.76; P=0.71). Cases and controls did not differ with respect to age (P=0.91), ICU length of stay (P=0.73), number of lines (P=0.95), number of lumens (P=0.22) and line dwell times (P=0.25), but did differ with respect to adherence to maximal sterile barrier precautions used for line placement (P≤0.001).
The authors said the CDC has recommended using the subclavian vein and avoiding the femoral vein for insertion of nontunneled, short-term access catheters to reduce the risk for CLABSIs. However, there are no evidence-based recommendations with regard to choosing among subclavian, jugular or femoral sites when other frequently manipulated devices (e.g., tracheostomy) that could potentially increase the risk for infection are in place.
A limited number of studies have observed a greater incidence of CLABSIs in patients with a tracheostomy. However, the studies are small in number and of questionable generalizability. “The purpose of our study is to further define the influence of tracheostomy on the risk of CLABSI in patients with internal jugular vein cannulation,” the authors wrote. Joseph S. Meltzer, MD, associate professor in the Department of Anesthesiology and Perioperative Medicine at UCLA, was the principal investigator of the study.
“In our critically ill adult patient population, we found no significant association between tracheostomy and risk of CLABSI in patients with IJ central lines after accounting for several well-studied predictors of infection,” the study concluded. “The lack of evidence to support this risk should be considered by practitioners when selecting a site for cannulation.”
Ms. Russell said their hypothesis was that a tracheostomy did not increase the risk for CLABSIs in patients with IJ catheters. “The results of our multivariate analysis, which included well-known risk factors for central line infection (e.g., line dwell time), supported the hypothesis,” she said.