University of Paris, INSERM, IAME, Paris, France.
Infection Control Program and WHO Collaborating Centre on Patient Safety, University of Geneva Hospitals and Faculty of Medicine, Geneva, Switzerland.
Clin Infect Dis. 2021 Sep 7;73(5):e1054-e1061. doi: 10.1093/cid/ciaa1817.
Ultrasound (US) guidance is frequently used in critically ill patients for central venous catheter (CVC) insertion. The effect of US on infectious risk remains controversial, and randomized controlled trials (RCTs) have assessed mainly noninfectious complications. This study assessed infectious risk associated with catheters inserted with US guidance vs use of anatomical landmarks.
We used individual data from 3 large RCTs for which a prospective, high-quality data collection was performed. Adult patients were recruited in various intensive care units (ICUs) in France as soon as they required short-term CVC insertion. We applied marginal Cox models with inverse probability weighting to estimate the effect of US-guided insertion on catheter-related bloodstream infections (CRBSIs, primary outcome) and major catheter-related infections (MCRIs, secondary outcome).We also evaluated insertion site colonization at catheter removal.
Our post hoc analysis included 4636 patients and 5502 catheters inserted in 2088 jugular, 1733 femoral, and 1681 subclavian veins, in 19 ICUs. US guidance was used for 2147 catheter insertions. Among jugular and femoral CVCs and after weighting, we found an association between US and CRBSI (hazard ratio [HR], 2.21 [95% confidence interval {CI}, 1.17-4.16]; P = .014) and between US and MCRI (HR, 1.55 [95% CI, 1.01-2.38]; P = .045). Catheter insertion site colonization at removal was more common in the US-guided group (P = .0045) among jugular and femoral CVCs in situ for ≤7 days (n = 606).
In prospectively collected data in which catheters were not randomized to insertion by US or anatomical landmarks, US guidance was associated with increased risk of infection.
超声（US）引导在危重症患者中常被用于中心静脉导管（CVC）插入。US 对感染风险的影响仍存在争议，并且随机对照试验（RCT）主要评估了非感染性并发症。本研究评估了 US 引导与使用解剖学标志插入导管相关的感染风险。
我们使用了来自 3 项大型 RCT 的个体数据，这些 RCT 进行了前瞻性、高质量的数据收集。一旦成年患者需要短期 CVC 插入，他们就会在法国的各种重症监护病房（ICU）中被招募。我们应用边缘 Cox 模型和逆概率加权来估计 US 引导插入对导管相关血流感染（CRBSI，主要结局）和主要导管相关感染（MCRI，次要结局）的影响。我们还评估了导管拔除时的插入部位定植情况。
我们的事后分析包括 4636 名患者和 5502 根导管，这些导管分别插入 2088 根颈内、1733 根股和 1681 根锁骨下静脉，涉及 19 个 ICU。2147 根导管插入使用了 US 引导。在颈内和股静脉 CVC 中，且经过加权后，我们发现 US 与 CRBSI 之间存在关联（风险比[HR]，2.21[95%置信区间{CI}，1.17-4.16]；P=0.014）和 US 与 MCRI 之间存在关联（HR，1.55[95% CI，1.01-2.38]；P=0.045）。在颈内和股静脉 CVC 原位放置≤7 天的情况下（n=606），导管插入部位在移除时的定植更为常见，这在使用 US 引导的组中更为常见（P=0.0045）。
在前瞻性收集的数据中，导管未随机分配至 US 或解剖学标志引导插入，US 引导与感染风险增加相关。
