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Safe central venous catheter insertion practice must extend beyond simply measuring catheter-associated bloodstream infections
Journal of Hospital Infection 90 (2015) 81e84 Available online at www.sciencedirect.com
Journal of Hospital Infection journal homepage: www.elsevierhealth.com/journals/jhin
Letters to the Editor
Safe central venous catheter insertion practice must extend beyond simply measuring catheter-associated bloodstream infections
truly patient-centred CVC insertion requires that definitions of safe practice extend beyond CABI incidence; for this reason, we wholeheartedly support the ongoing use of RUG. Conflict of interest statement None declared. Funding None.
Sir,
References
Cartier et al.1 concluded that the use of real-time ultrasound guidance (RUG) for central venous catheter (CVC) insertion has little benefit in relation to catheter-associated bloodstream infection (CABI). We question the validity of this assertion. As acknowledged by Cartier et al., this was not a randomized study. Interoperator and interpatient variability may therefore have biased the results significantly. Furthermore, the study was performed in the context of CVCs inserted by anaesthetists in acute care or intensive care areas of the hospital. This patient cohort does not necessarily reflect the characteristics of other patient groups who require central venous access (e.g. patients requiring parenteral nutrition, chemotherapy or haemodialysis). No detail was given regarding the operators’ previous experience with CVC insertion. Significant recent experience is known to be predictive of successful central venous cannulation,2,3 and in practice, many CVCs are inserted by junior doctors4 who are not confident performing the procedure.5 Data generated by experienced anaesthetists cannot necessarily be extrapolated to the practice of inexperienced junior doctors. We were disappointed that Cartier et al. did not report the number of skin punctures associated with each CVC insertion. We presume this is the means by which RUG modifies CABI. Similarly, other measures of safe practice, including those described by Cartier et al. in their introduction, were not reported. These include the occurrence of periprocedural bleeding, pneumothorax or cardiac arrhythmia. Table IV of the article by Cartier et al. demonstrates reduced all-cause mortality in the group of patients with RUG CVC placement. This was highly significant, demonstrating the utility of RUG beyond simply reducing CABI, and suggesting an influence of RUG on these other unreported factors. We welcome all efforts to delineate measures that will reduce complications associated with CVC insertion. However,
1. Cartier V, Haenny A, Inan C, Walder B, Zingg W. No association between ultrasound-guided insertion of central venous catheters and bloodstream infection: a prospective observational study. J Hosp Infect 2014;87:103e108. 2. Sznajder JI, Zveibil FR, Bitterman H, Weiner P, Bursztein S. Central vein catheterization. Failure and complication rates by three percutaneous approaches. Arch Intern Med 1986;146:259e261. 3. Smith CC, Huang GC, Newman LR, et al. Simulation training and its effect on long-term resident performance in central venous catheterization. Simul Healthc 2010;5:146e151. 4. Berns JS, O’Neill WC. Performance of procedures by nephrologists and nephrology fellows at U.S. nephrology training programs. Clin J Am Soc Nephrol 2008;3:941e947. 5. Clark EG, Schachter ME, Palumbo A, Knoll G, Edwards C. Temporary hemodialysis catheter placement by nephrology fellows: implications for nephrology training. Am J Kidney Dis 2013;62:474e480.
S.W. Olivera,b,c,* P.C. Thomsona A.G. Jardinea,b a Glasgow Renal and Transplant Unit, Western Infirmary, Glasgow, UK b
School of Medicine, University of Glasgow, Glasgow, UK
c
Department of Medical Education, NHS Lanarkshire, UK
* Corresponding author. Address: Postgraduate Office, Wishaw General Hospital, 50 Netherton Street, Wishaw ML2 0DP, UK. Tel.: þ44 (0)7974 085 992. E-mail address: [email protected] (S.W. Oliver). Available online 7 January 2015 http://dx.doi.org/10.1016/j.jhin.2014.11.021 ª 2015 The Healthcare Infection Society. Published by Elsevier Ltd. All rights reserved.
Journal of Hospital Infection journal homepage: www.elsevierhealth.com/journals/jhin
Letters to the Editor
Safe central venous catheter insertion practice must extend beyond simply measuring catheter-associated bloodstream infections
truly patient-centred CVC insertion requires that definitions of safe practice extend beyond CABI incidence; for this reason, we wholeheartedly support the ongoing use of RUG. Conflict of interest statement None declared. Funding None.
Sir,
References
Cartier et al.1 concluded that the use of real-time ultrasound guidance (RUG) for central venous catheter (CVC) insertion has little benefit in relation to catheter-associated bloodstream infection (CABI). We question the validity of this assertion. As acknowledged by Cartier et al., this was not a randomized study. Interoperator and interpatient variability may therefore have biased the results significantly. Furthermore, the study was performed in the context of CVCs inserted by anaesthetists in acute care or intensive care areas of the hospital. This patient cohort does not necessarily reflect the characteristics of other patient groups who require central venous access (e.g. patients requiring parenteral nutrition, chemotherapy or haemodialysis). No detail was given regarding the operators’ previous experience with CVC insertion. Significant recent experience is known to be predictive of successful central venous cannulation,2,3 and in practice, many CVCs are inserted by junior doctors4 who are not confident performing the procedure.5 Data generated by experienced anaesthetists cannot necessarily be extrapolated to the practice of inexperienced junior doctors. We were disappointed that Cartier et al. did not report the number of skin punctures associated with each CVC insertion. We presume this is the means by which RUG modifies CABI. Similarly, other measures of safe practice, including those described by Cartier et al. in their introduction, were not reported. These include the occurrence of periprocedural bleeding, pneumothorax or cardiac arrhythmia. Table IV of the article by Cartier et al. demonstrates reduced all-cause mortality in the group of patients with RUG CVC placement. This was highly significant, demonstrating the utility of RUG beyond simply reducing CABI, and suggesting an influence of RUG on these other unreported factors. We welcome all efforts to delineate measures that will reduce complications associated with CVC insertion. However,
1. Cartier V, Haenny A, Inan C, Walder B, Zingg W. No association between ultrasound-guided insertion of central venous catheters and bloodstream infection: a prospective observational study. J Hosp Infect 2014;87:103e108. 2. Sznajder JI, Zveibil FR, Bitterman H, Weiner P, Bursztein S. Central vein catheterization. Failure and complication rates by three percutaneous approaches. Arch Intern Med 1986;146:259e261. 3. Smith CC, Huang GC, Newman LR, et al. Simulation training and its effect on long-term resident performance in central venous catheterization. Simul Healthc 2010;5:146e151. 4. Berns JS, O’Neill WC. Performance of procedures by nephrologists and nephrology fellows at U.S. nephrology training programs. Clin J Am Soc Nephrol 2008;3:941e947. 5. Clark EG, Schachter ME, Palumbo A, Knoll G, Edwards C. Temporary hemodialysis catheter placement by nephrology fellows: implications for nephrology training. Am J Kidney Dis 2013;62:474e480.
S.W. Olivera,b,c,* P.C. Thomsona A.G. Jardinea,b a Glasgow Renal and Transplant Unit, Western Infirmary, Glasgow, UK b
School of Medicine, University of Glasgow, Glasgow, UK
c
Department of Medical Education, NHS Lanarkshire, UK
* Corresponding author. Address: Postgraduate Office, Wishaw General Hospital, 50 Netherton Street, Wishaw ML2 0DP, UK. Tel.: þ44 (0)7974 085 992. E-mail address: [email protected] (S.W. Oliver). Available online 7 January 2015 http://dx.doi.org/10.1016/j.jhin.2014.11.021 ª 2015 The Healthcare Infection Society. Published by Elsevier Ltd. All rights reserved.