Guidewire exchange vs new site placement for temporary dialysis catheter insertion in ICU patients: is there a greater risk of colonization or dysfunction?

Abstract

BackgroundIntensive care unit (ICU) patients require dialysis catheters (DCs) for renal replacement therapy (RRT). They carry a high risk of developing end-stage renal disease, and therefore their vascular access must be preserved. Guidewire exchange (GWE) is often used to avoid venipuncture insertion (VPI) at a new site. However, the impact of GWE on infection and dysfunction of DCs in the ICU is unknown. Our aim was to compare the effect of GWE and VPI on DC colonization and dysfunction in ICU patients.MethodsUsing data from the ELVIS randomized controlled trial (RCT) (1496 ICU adults requiring DC for RRT or plasma exchange) we performed a matched-cohort analysis. Cases were DCs inserted by GWE (n = 178). They were matched with DCs inserted by VPI. Matching criteria were participating centre, simplified acute physiology score (SAPS) II +/-10, insertion site (jugular or femoral), side for jugular site, and length of ICU stay before DC placement. We used a marginal Cox model to estimate the effect of DC insertion (GWE vs. VPI) on DC colonization and dysfunction.ResultsDC colonization rate was not different between GWE-DCs and VPI-DCs (10 (5.6 %) for both groups) but DC dysfunction was more frequent with GWE-DCs (67 (37.6 %) vs. 28 (15.7 %); hazard ratio (HR), 3.67 (2.07–6.49); p < 0.01). Results were similar if analysis was restricted to DCs changed for dysfunction.ConclusionsGWE for DCs in ICU patients, compared with VPI did not contribute to DC colonization or infection but was associated with more than twofold increase in DC dysfunction.Trial registrationThis study is registered with ClinicalTrials.gov, number NCT00563342. Registered 2 April 2009.Electronic supplementary materialThe online version of this article (doi:10.1186/s13054-016-1402-6) contains supplementary material, which is available to authorized users.

A state of the art review on optimal practices to prevent, recognize, and manage complications associated with intravascular devices in the critically ill

“…The risk of DC colonization was demonstrated to be steady over time for intermittent hemodialysis [21,22] but to increase sharply after 10 days for continuous RRT [21]. In two observational studies, the risk of HDC colonization for HDCs replaced for dysfunction did not differ between HDCs inserted by new puncture or exchanged over a guidewire [20,23]. In a randomized study including a mixed ICU and non-ICU population, minocyclinerifampicin-coated HDCs failed to decrease the rate of colonization, but did reduce infection (0/66 versus 7/64 CRBSI in the treatment versus control arm, respectively) [24].…”

Acceso vascular en apoyo renal agudo

“…De igual forma, la colocación de un nuevo catéter temporal podría llevarse a cabo a través de una guía metálica a partir de un acceso venoso central previo, evitando así la técnica de punción. Coupez, et al tomaron 178 pacientes procedentes de una muestra de pacientes incluidos en un ECCA previo, encontrando un porcentaje de colonización igual para ambas técnicas (5.6%), aunque el riesgo de disfunción del acceso fue mayor en el caso de colocación por guía metálica vs. por punción (razón de tasas de riesgo o hazard ratio [HR]: 3.67 [2.07 ÷ 6.49]) 5 . De esta forma, en pacientes de alto riesgo de complicaciones por punción, el cambio del acceso por guía metálica es considerada una técnica segura.…”

Vascular access, membranes and circuit for CRRT

“…While there is no definitive evidence demonstrating that time-driven exchanges of non-infected, functioning STDCs decreases infections, recommendations of routine exchanges vary from 21 days for the internal jugular sites to 5-7 days for the femoral site. When existing catheters are exchanged, although the risk of colonization or infection is the same whether the exchange is via either guidewire or de novo puncture, 43,44 catheter dysfunction is more frequent when exchanging over a guidewire. 44 The presence of a suspected catheter-related bacteremia triggers the prompt removal of the STDC.…”

“…When existing catheters are exchanged, although the risk of colonization or infection is the same whether the exchange is via either guidewire or de novo puncture, 43,44 catheter dysfunction is more frequent when exchanging over a guidewire. 44 The presence of a suspected catheter-related bacteremia triggers the prompt removal of the STDC. Implementing a catheter-free period is desirable, but must be decided on an individual basis.…”