Effect of Subcutaneous Tunneling on Internal Jugular Catheter-Related Sepsis in Critically III Patients

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Abstract
Objective. —To evaluate the effect of catheter tunneling on internal jugular catheter-related sepsis in critically ill patients. Design. —A prospective randomized controlled study involving 3 intensive care units (ICUs), stratified by number of catheter lumina (1 or 2) and center. Setting. —The 10-bed medical-surgical and 10-bed surgical ICUs at Saint Joseph Hospital and 8-bed surgical ICU at Clinique de la Défense, Paris, France. Patients. —Every patient older than 18 years admitted to the ICUs between March 1,1993, and July 17,1996, who required a jugular venous catheter for more than 48 hours. Intervention. —Random allocation to tunneled or nontunneled catheters. Measurements. —Times to occurrence of systemic catheter-related sepsis, catheter-related septicemia, or a quantitative catheter-tip culture with a cutoff of 103 colony-forming units per milliliter. Results. —A total of 241 patients were randomized. Ten patients in whom jugular puncture was not achieved were subsequently excluded. The proportion of patients receiving mechanical ventilation (87%) and mean±SD age (65±4 years), Simplified Acute Physiologic Score (13.3±4.9), Organ System Failure score (1.5±1.0), and duration of catheterization (8.7±5.0 days) were similar in both groups. Taking into account the first 231 catheters (114 nontunneled [control], 117 tunneled), we found that tunnelization decreased catheter-related sepsis (odds ratio [OR], 0.33; 95% confidence interval [CI], 0.13-0.83; P=.02), catheter-related septicemia (OR, 0.23; 95% CI, 0.07-0.81; P=.02), and, though not statistically significant, positive quantitative tip-culture rate (OR, 0.62; 95% CI, 0.35-1.10; P=.10). These results were slightly modified after adjustment on parameters either imbalanced between both groups (duration of catheter placement and cancer at admission) or prognostic (insertion by a resident, use of antibiotics at catheter insertion, cancer, and sex). Conclusion. —The incidence of internal jugular catheter-related infections in critically ill patients can be reduced by using subcutaneous tunnelization.