A recent JAMA article (Parienti et al, JAMA 2008) was presented in journal club today which involved a randomized control trial looking at infectious and other complications seen in patients with acute kidney injury in an ICU who were randomized to receive dialysis via either (a) a femoral catheter, or (b) an intrajugular catheter.Traditionally, I have always been taught to do an intrajugular catheter if at all possible given the additional infectious risks associated with long-term femoral catheters. Indeed, the KDOQI Guidelines state that temporary femoral catheters should be left in for only 5 days whereas temporary IJ catheters may be left in for up to 3 weeks. Interestingly, however, the study found no significant differences in infection (as assessed by catheter tip culture growth) between the two groups!
The study did find that patients who are more obese (BMI >28) have a greater infectious risk with femoral compared to IJ catheters. What was more suprising, however, was their finding that patients in the "low BMI" group (BMI <24) appeared to benefit from a femoral catheter compared to an IJ catheter. Why this should be the case is not entirely clear.
Does this paper change my clinical practice? Not really, but it does make me feel justified in occasions where I'd prefer to do a femoral line (e.g. coagulopathy, relative urgency to start dialysis, unusual neck or thoracic anatomy), and it also confirms my suspicion that it's better (and often technically easier) to do a neck line in a morbidly obese patient.
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