Context Based on concerns about the risk of infection, the jugular site is often preferred over the femoral site for short-term dialysis vascular access. Objective To determine whether jugular catheterization decreases the risk of nosocomial complications compared with femoral catheterization. Design, Setting, and Patients A concealed, randomized, multicenter, evaluator-blinded, parallel-group trial (the Cathedia Study) of 750 patients from a network of 9 tertiary care university medical centers and 3 general hospitals in France conducted between May 2004 and May 2007. The severely ill, bed-bound adults had a body mass index (BMI) of less than 45 and required a first catheter insertion for renal replacement therapy. Intervention Patients were randomized to receive jugular or femoral vein catheterization by operators experienced in placement at both sites. Main Outcome Measures Rates of infectious complications, defined as catheter colonization on removal (primary end point), and catheter-related bloodstream infection. Results Patient and catheter characteristics, including duration of catheterization, were similar in both groups. More hematomas occurred in the jugular group than in the femoral group (13/366 patients [3.6%] vs 4/370 patients [1.1%], respectively; P = .03). The risk of catheter colonization at removal did not differ significantly between the femoral and jugular groups (incidence of 40.8 vs 35.7 per 1000 catheter-days; hazard ratio [HR], 0.85; 95% confidence interval [CI], 0.62-1.16; P = .31). A prespecified subgroup analysis demonstrated significant qualitative heterogeneity by BMI (P for the interaction term  28.4). The rate of catheter-related bloodstream infection was similar in both groups (2.3 vs 1.5 per 1000 catheter-days, respectively; P = .42). Conclusion Jugular venous catheterization access does not appear to reduce the risk of infection compared with femoral access, except among adults with a high BMI, and may have a higher risk of hematoma. Trial Registration clinicaltrials.gov Identifier: NCT00277888

https://jamanetwork.com/journals/jama/articlepdf/181954/jce80002_2413_2422.pdf

Femoral vs jugular venous catheterization and risk of nosocomial events in adults requiring acute renal replacement therapy: a randomized controlled trial.

PurposeCentral venous catheterization (CVC) is increasingly taught by simulation. The authors reviewed the literature on the effects of simulation training in CVC on learner and clinical outcomes.MethodThe authors searched computerized databases (1950 to May 2010), reference lists, and consi

/pdf/use-of-simulation-based-education-to-improve-outcomes-of-3xjk5ilqdh.pdf

Use of Simulation-Based Education to Improve Outcomes of Central Venous Catheterization: A Systematic Review and Meta-Analysis

Background. Increasingly, peripherally inserted central venous catheters (PICCs) are placed for prolonged intravenous access. Few data exist regarding risk factors for central line–associated bloodstream infection (CLABSI) complicating PICCs in hospitalized children, especially children hospitalized outside the intensive care unit (ICU).

Methods. We identified all children with a PICC inserted at The Johns Hopkins Hospital (Baltimore, MD) from 1 January 2003 through 31 December 2009 and used Poisson regression models to identify risk factors for PICC-associated CLABSIs.

Results. A total of 2592 PICCs were placed in 1819 children. One hundred sixteen CLABSIs occurred over 44,972 catheter-days (incidence rate [IR], 2.58 cases per 1000 catheter-days; 95% confidence interval [CI], 2.07–3.00 cases per 1000 catheter-days). Independent predictors of CLABSI in the entire cohort included PICC dwell time of ≥21 days (IR ratio [IRR], 1.53; 95% CI, 1.05–2.26), parenteral nutrition as indication for insertion (IRR, 2.24; 95% CI, 1.31–3.84), prior PICC-associated CLABSI (IRR, 2.48; 95% CI, 1.18–5.25), underlying metabolic condition (IRR, 2.07; 95% CI, 1.14–3.74), and pediatric ICU exposure during hospitalization (IRR, 1.80; 95% CI, 1.18–2.75). Risk factors for CLABSI in children without PICU exposure included younger age, underlying malignancy and metabolic conditions, PICCs inserted in the lower extremity, and a prior PICC-associated CLABSI.

Conclusions. Prolonged catheter dwell time, pediatric ICU exposure, and administration of parenteral nutrition as the indication for PICC insertion are important predictors of PICC-associated CLABSI in hospitalized children. A careful assessment of these risk factors may be important for future success in preventing CLABSIs in hospitalized children with PICCs.

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Central Line–Associated Bloodstream Infection in Hospitalized Children with Peripherally Inserted Central Venous Catheters: Extending Risk Analyses Outside the Intensive Care Unit

Ultrasound-guided peripheral intravenous access program is associated with a marked reduction in central venous catheter use in noncritically ill emergency department patients

This article has been corrected. The original version (PDF) is appended to this article as a supplement. Simulation is a versatile technique used in a variety of health care settings for a variety ...

http://unmhospitalist.pbworks.com/w/file/fetch/64524342/Schmidt_Sim_2013.pdf

Simulation Exercises as a Patient Safety Strategy

Prospective cohort study of central venous catheters among internal medicine ward patients

BACKGROUND

Central venous catheters placed in femoral veins increase the risk of complications At our institution, residents place most catheters in the femoral vein



OBJECTIVE

Determine whether a hands-on educational session reduced femoral venous catheterization and improved residents' confidence and adherence to recommendations for infection control



DESIGN

Firm-based clinical trial between November 2004 and March 2005



SETTING

General medical wards of Cook County (Stroger) Hospital (Chicago, IL), a public teaching hospital



PARTICIPANTS

Internal medicine residents (n = 150)



INTERVENTION

Before their 4-week rotation, intervention-firm residents received a lecture and practiced placing catheters in mannequins; control-firm residents received the usual training



MEASUREMENTS

Venous insertion site, adherence to recommendations for infection control, knowledge and confidence about catheter insertion, and catheter-associated complications



RESULTS

Residents inserted 54 catheters, or 024 insertions per resident per 4-week rotation There was a nonsignificant decrease in femoral insertions for nondialysis catheters in the intervention group compared to the control group (44% vs 58%), difference: −14% (95% CI, −52% to 24%) The intervention significantly increased residents' knowledge of complications related to femoral vein catheterization and temporarily increased their confidence about placing internal jugular or subclavian venous catheters Intervention-group residents were more likely to use masks during catheterization (risk ratio, 22; 95% CI, 13-27), but other practices were similar



CONCLUSIONS

Our intervention improved residents' knowledge of complications and use of masks during catheter insertion; however, it did not significantly change venous insertion sites Catheter insertions on our general medicine wards are infrequent, and the skills acquired during the skills-building session may have deteriorated given the few clinical opportunities for reinforcement Journal of Hospital Medicine 2007;2:135–142 © 2007 Society of Hospital Medicine

/pdf/firm-based-trial-to-improve-central-venous-catheter-aud2win6pu.pdf

Julio A. Miranda

Papers

Prospective cohort study of central venous catheters among internal medicine ward patients

Firm‐based trial to improve central venous catheter insertion practices