Friday, April 5, 2013

Fellow: n. A Trainee MD who does the same research as his attending MD when he was a fellow, but got the opposite, ergo, publishable result.

video
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.

Comments posted to EMCrit Blog concerning the meta-analysis above.


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 cutdowns. 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.


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