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Home , Central venous catheter, SAPS II

Prospective study of arterial and central venous colonization and of arterial- and –related bacteremia in intensive care units*

Ousmane Traoré, MD, PhD; Jérôme Liotier, MD; Bertrand Souweine, MD, PhD

Objective: To compare the rates of positive quantitative culture forming units/mL. Catheter-related bacteremia was defined by a (PQC) of arterial catheter (AC) and central venous catheter (CVC) PQC and a positive for the same microorganism. The tips and of CVC- and AC-related bacteremia in cumulative incidence (PQCs/number of inserted) was .(44. ؍ patients undergoing placement of both ACs and CVCs. 9.4% (29/308) for CVCs and 7.7% (23/299) for ACs (p Design: Prospective, descriptive survey. To control for a dif- Incidence density (PQCs/1,000 catheter days) was 12.0 for CVCs ference in the severity of patients having an AC or CVC, only versus 9.3 for ACs. At the femoral site, there was no significant patients having both an AC and a CVC were included. difference between CVCs and ACs in the cumulative incidences Setting: An adult, nine-bed medical/surgical intensive care and incidence densities of PQCs. Two instances of catheter- unit at a university teaching hospital. related bacteremia were observed, one involving a CVC and one Subjects: The analysis included 308 CVCs and 299 ACs inserted involving an AC. in 212 severely ill patients, with a mean ؎ SD Simplified Acute Conclusions: Among severely ill patients with both CVCs and Physiology Score II of 52 ؎ 22 and an intensive care unit mortality ACs, the epidemiology of PQCs of CVCs and ACs is comparable of 33% (69 of 212). when the same infection control measures are used for the Interventions: None. Measurements and Main Results: The same insertion and insertion and maintenance of both types of catheters. (Crit Care maintenance procedures were used for both types of catheter. A Med 2005; 33:1276–1280) PQC was defined by a catheter tip culture yielding >103 colony KEY WORDS: infections; arterial; central venous catheter

rterial catheters (ACs) are fre- niques have reported AC-related infec- published reports comparing rates of pos- quently used for continuous tions (4–7). One randomized study sug- itive quantitative culture (PQC) of CVCs hemodynamic of gested that the use of sterile barrier and ACs or of CVC- and AC-related bac- and drawing blood samples precautions when inserting ACs without teremia in a patient group undergoing Afrom critically ill patients. These patients both types of catheterization. Our pro- the use of a guidewire has no greater are often at increased risk of nosocomial effect on decreasing colonization or in- spective study was designed to compare infections because of their underlying fection than standard procedure, unlike these rates of colonizations/infections in , and catheter-related infection is with central venous catheters (CVCs) (7). an intensive care unit (ICU) where the one of the main severe complications of The authors noted that the incidence of insertion and maintenance procedures arterial or central venous catheterization AC-related infectious complications was used for ACs were the same as those for (1–3). comparable to that of CVC-related infec- CVCs. Most reports on complications related tious complications in the literature. to ACs have focused on mechanical prob- However, that study (7), like most MATERIALS AND METHODS lems. Recently a few investigators using other published reports (1, 5, 7–11), in- standardized quantitative culture tech- Study Population. This prospective study volved ACs only; thus, comparison of was performed in a nine-bed medical/surgical rates of AC- and CVC-related infections ICU at the university teaching hospital of Cler- was not possible. A few studies have de- mont-Ferrand, France, between September *See also p. 1437. scribed infectious complications of CVCs 15, 2000, and December 31, 2002. All the From the Service de Réanimation Médicale Poly- patients admitted to the ICU during this pe- valente et Néphrologie (JL, BS) and the Service and ACs that were placed in two different d’Hygiène Hospitalière (OT), Hôpital G. Montpied, Cler- patient populations (4, 12). This makes riod were eligible. All patients who required Ն mont-Ferrand, France. comparison difficult because there may CVC and AC placement for a duration 48 hrs Supported, in part, by a grant from the Faculté de be differences in the severity of the pa- during their hospital stay were included in the study. Only the catheters placed and removed Médecine de Clermont-Ferrand, Clermont-Ferrand, tients’ condition, and severity is a deter- France. The authors have no financial interests to in the unit were analyzed, whether CVCs and disclose. mining factor of risk of infection since ACs were in place at the same time or sequen- Copyright © 2005 by the Society of Critical Care the most critically ill patients are those tially. All patients underwent placement of and Lippincott Williams & Wilkins whose CVCs and ACs are handled the polyurethane single-lumen or multiple-lumen DOI: 10.1097/01.CCM.0000166350.90812.D4 most. To our knowledge there are no CVCs (from Seldiflex Plastimed, St. Leu-la-

1276 Crit Care Med 2005 Vol. 33, No. 6 Foret, France, during the period of September culture technique previously described by inserted in 212 patients—128 men and 15, 2000, through December 31, 2001, and Brun-Buisson et al. (17). For patients exhibit- 84 women (sex ratio, 1.52)—with a mean from Arrow-Howes, Reading, PA, until Decem- ing clinical signs of infection (fever, chill, hy- Ϯ SD age of 61.4 Ϯ 17 yrs (median, 66 ber 31, 2002) and ACs (Leader Cath, Vygon, potension, leukocytosis/leukopenia), periph- yrs), a median SOFA score at 24 hrs of 7, eral blood samples were collected at the time Ecouen, France). The CVCs and the ACs used and a mean SAPS II at 24 hrs of 52 Ϯ 22 in this study had no or antiseptic of catheter removal and subsequently cul- properties. The was used tured. Standard microbiological methods were (median, 50). Of the 212 patients, 119 for catheter insertion. In our unit, CVCs are used to identify the colonizing/infecting or- (56%) had invasive mechanical ventila- used to deliver medications and nutritional ganisms. tion Ͼ48 hrs and 79 (37%) had at least support and to measure central venous pres- Definitions. A PQC was defined as a quan- one session while in the ICU. For 3 sure. CVCs are never used for blood sampling. titative culture tip yielding Ͼ10 colony form- these 212 patients, the mean Ϯ SD length ACs are used to draw blood samples and to ing units/mL. Catheter-related bacteremia of ICU stay was 17.2 Ϯ 17.9 days (median, monitor arterial blood pressure. (CRB) was defined by isolation of the same 10; range, 2–110), the mean omega score/ For both CVCs and ACs, the indication for phenotypic microorganisms from both periph- day was 15.6 Ϯ 7.3 (median, 14.8; range, catheterization, the insertion site, and the eral blood and catheter tip in a culture grow- 3.9–51), and the ICU mortality rate was number of CVC lumens were left to the dis- ing Ͼ103 cfu/mL when there was no other cretion of the attending physician. CVCs were overt source of the bacteremia except the 33% (69/212). not tunneled and no guidewire-assisted catheter. Catheterizations. Of the 308 CVCs, 19 changing of catheters was done for either Statistical Analysis. PQC and CRB rates (6%) were single-lumen, 23 (8%) were CVCs or ACs. All of the CVCs and ACs were were expressed in terms of cumulative inci- double-lumen, and 266 were triple- inserted at the bedside by the attending phy- dences and incidence densities. Cumulative lumen (86%). The mean Ϯ SD duration of sicians. Catheter insertion and of the incidence is expressed as percentage and inci- CVC placement was 7.9 Ϯ 4.9 days (me- insertion site were done according to our pre- dence density as PQCs per 1,000 catheter days. dian, 7 days), and it was longer for CVCs viously published ICU procedure (13), which Categorical variables were compared by the inserted at the subclavian site (p ϭ .005). requires the wearing of a cap, mask, gown, and chi-square test or Fisher’s exact test, and con- CVC-PQC was observed in 29 (9.4%) of sterile gloves for CVC and AC insertion. The tinuous variables were compared by analysis of puncture site was prepared with alcoholic so- variance or by Mann-Whitney test or Kruskall- 308 cases, with no significant difference lution of 0.5% , and the sur- Wallis test when necessary. The Kaplan-Meier in relation to the number of lumens (p ϭ rounding areas were covered with sterile test was used to compare the risk of PQCs over .38). The incidence density of PQC was 12 drapes. A sterile, occlusive, adhesive, transpar- time between CVCs and ACs. Two-tailed p val- per 1,000 days of CVC use. There was no ent dressing (Tegaderm, 3M, London, ON, ues Ͻ .05 were considered to indicate statis- difference in the mean duration of CVC Canada) was applied. For both CVCs and ACs, tical significance. Analyses were performed placement with or without PQC (7.9 Ϯ occlusive dressings and intravenous tubes with Epi Info 6 software (Centers for Disease 2.8 days [median, 8 days] vs. 7.9 Ϯ 5.1 were routinely changed every 48 hrs by a Control and Prevention, Atlanta, GA). [median, 7 days; p ϭ .8]). On the basis of nurse wearing a cap, mask, and sterile gloves. the median duration of CVC placement, Informed consent was not required because all RESULTS procedures were routine. The ethics commit- the PQC rate was higher for CVCs that tee of the hospital was nevertheless informed Study Population. During the study remained in place Ͼ7 days than for those about the study and raised no objections. period 800 patients were admitted to the removed earlier (13.1% vs. 6.1%; p ϭ Data Collection. We recorded demographic ICU, of whom 647 had a stay Ͼ48 hrs. Of .04). The rate of PQC was greater with data including age and sex, -related Or- these, 450 had a CVC or AC in place for internal jugular or femoral catheters gan Failure Assessment (SOFA) score (14), Ͼ48 hrs, and all catheters were inserted than with those placed via the subclavian Simplified Acute Physiology Score (SAPS) II at and removed during their ICU stay. In 86 route (relative risk, 3.6 vs. 3.8; 95% con- 24 hrs (15), use of dialysis or mechanical ven- patients, CVCs were placed without AC fidence interval, 1.1–12 vs. 1.03–14.2; p tilation for Ͼ48 hrs during hospital stay, ϭ .02 vs. p ϭ .03). The characteristics of workload as assessed by total daily omega insertion; in 131 patients, ACs were score (16), length of ICU stay, and ICU mor- placed without CVC insertion; and in 233 the CVC catheterizations are shown in tality. We also recorded the type of catheter patients, both CVCs and ACs were placed. Table 1. (venous or arterial), the number of lumens of Of these 233 patients, 21 (9.0%) were The 299 ACs were mostly placed in the the CVCs, insertion site, and duration of place- excluded because CVC or AC culture re- radial site (68%). The mean Ϯ SD dura- ment. All these data were entered in an Excel sults were not available (11 and 12 cases, tion of AC placement was 8.2 Ϯ 5.3 days file. respectively). Thus, the study involved (median, 7 days), with a difference in AC The CVCs and ACs were not changed after 607 catheters (308 CVCs and 299 ACs) catheterization duration according to the a fixed insertion time but were removed when they were no longer needed or when the pa- tient exhibited signs of infection (fever or sep- sis) that had no other obvious cause. The CVCs Table 1. Characteristics of the 308 central venous catheterizations and ACs used in patients who died were in- No. of CVCs Duration (Days), Cumulative Incidence: cluded. The skin surrounding the insertion Route (%) Mean Ϯ SD PQC-CVC/No. of CVCs (%) site was carefully disinfected with chlorhexi- dine before catheter removal. The CVCs and Any 308 (100) 7.9 Ϯ 4.9 29/308 (9.4) ACs were removed under aseptic conditions. A Internal jugular 160 (51.9) 7.3 Ϯ 4.5a 19/160 (11.9)b 5-cm distal segment (tip) was collected in ster- Subclavian 92 (29.9) 9.0 Ϯ 5.2 3/92 (3.3) ile containers from all catheters. All catheter Femoral 56 (18.2) 7.5 Ϯ 5.4 07/56 (12.5) tips were sent to the microbiology laboratory for quantitative culture. CVC, central venous catheter; PQC, positive quantitative culture. Microbiology. All the samples were cul- ap ϭ .005 (Kruskal-Wallis test) between internal jugular, subclavian, and femoral routes; bp ϭ .04 tured by means of the simplified quantitative (␹2 test) between internal jugular, subclavian, and femoral routes.

Crit Care Med 2005 Vol. 33, No. 6 1277 insertion site (p ϭ .03). AC-PQC was ob- with CVC- or AC-PQC and 52.6 Ϯ 22.0 for negative staphylococci. No Candida spe- served in 23 (7.7%) of 299 cases, with no the 170 patients without CVC- or AC-PQC cies organisms were isolated in the PQCs. significant difference according to the in- (p ϭ .71). SAPS II was not different be- ϭ sertion site (p .65). The PQC incidence tween the 26 patients with CVC-PQC and DISCUSSION density was 9.3 per 1,000 days of AC use. the 186 patients without CVC-PQC (47.7 There was no difference in the mean du- Ϯ 21.0 vs. 52.9 Ϯ 22.0; p ϭ .34). SAPS II Our study shows that the epidemiol- ration of AC placement with or without was 53.3 Ϯ 21.0 for the 22 patients with ogy of PQCs of CVCs and ACs are compa- PQC (9.8 Ϯ 8.1 days vs. 8.1 Ϯ 4.9 days; p AC-PQC and 52.2 Ϯ 22.0 for the 190 rable. The same results were observed ϭ .33). On the basis of the median dura- patients without AC-PQC (p ϭ .8). with catheterizations of the femoral tion of AC placement, the PQC rate did Thirteen of 212 patients had an ICU- and . We compared the epidemi- not differ between ACs left in place Ͼ7 acquired bloodstream infection. Of these ology of PQCs of CVCs and ACs and of days and those removed before day 8 infections, two were catheter-related: CVC- and AC-related bacteremia when (7.9% vs. 7.5%; p ϭ .89). The character- CVC-related bacteremia due to Staphylo- the same infection control measures were istics of the AC catheterizations are coccus aureus and AC-related bacteremia applied for the insertion and removal of shown in Table 2. due to Enterobacter species. Thus, the the two types of catheter. It might have Comparison of CVCs and ACs. There cumulative incidence and incidence den- been expected to find differences between was no difference in catheterization du- sity of catheter-related bacteremia were, the rates of CVC and AC infectious com- ration between CVCs and ACs (p ϭ .70). respectively, 0.32% and 0.40/1,000 days plications, because CVCs and ACs are dis- There was no difference in the cumula- for CVCs and 0.33% and 0.41/1,000 days parate types and have different uses. tive incidence of PQC between CVCs and for ACs. However, since there were only CVCs are used to measure hemodynamic ACs or in the incidence density of PQC two instances of catheter-related bactere- variables, to draw blood samples, and to (relative risk, 1.22 vs. 1.29; 95% confi- mia, we cannot draw any meaningful deliver medications and nutritional sup- dence interval, 0.73–2.07 vs. 0.75–2.23; p conclusion about the rates of CVC- vs. . ACs are used to monitor invasive ϭ .45 and p ϭ .41). The cumulative in- AC-related bacteremia. arterial blood pressure and for drawing cidence of PQC did not differ between The causative germs isolated in the blood samples. It is noteworthy that in CVCs and ACs in relation to the femoral PQCs of the CVCs and ACs are given in our unit, none of the CVCs were intro- site (p ϭ .59); nor did the incidence den- Table 3. They were mainly Gram-positive ducers—thus, at no time were pulmo- sity differ (16.7 per 1,000 days of CVC use cocci, with a predominance of coagulase- nary catheters placed through them— vs. 12.8 per 1,000 days of AC use; p ϭ .78). There was no difference between the rates of CVC-PQC and AC-PQC when the Table 2. Characteristics of the 299 arterial catheterizations catheters were placed by a senior physi- Duration (Days), Cumulative Incidence: cian (20/191 [10.4%] vs. 15/163 [9.2%]; p Route No. of ACs (%) Mean Ϯ SD PQC-AC/No. of ACs (%) ϭ .69). Similarly, there was no difference between the rates when the catheters Any 299 (100) 8.2 Ϯ 5.3 23/299 (7.7) were placed by a resident (5/117 [7.7%] Radial 203 (68) 8.4 Ϯ 5.5a 15/203 (7.4)b Ϯ vs. 8/136 [5.9%]; p ϭ .57). Brachial 30 (10) 9.3 4.4 2/30 (6.7) Femoral 66 (22) 7.1 Ϯ 4.6 6/66 (9.1) In 114 patients, CVCs and ACs were inserted on the first day of ICU admis- AC, arterial catheter; PQC, positive quantitative culture. sion. The duration of catheterization was ap ϭ .03 (Kruskal-Wallis test) between radial, brachial, and femoral routes; bp ϭ .88 (␹2 test) 7.3 Ϯ 5.0 days (median, 7 days) for CVCs between radial, brachial, and femoral routes. and 7.9 Ϯ 4.9 (median, 7 days) for ACs (p ϭ .41). There was no difference between CVCs and ACs in the cumulative inci- dence of PQC (7/114 [6.1%] vs. 9/114 [7.9%]; p ϭ .6). The incidence density was 8.4 per 1,000 days of CVC use and 10.0 per 1,000 days of AC use (p ϭ .46). Figure 1 shows an actuarial survival curve for PQCs of CVCs and ACs. The Kaplan-Meier test estimated that the risk of PQCs in relation to the duration of catheterization did not differ over time between CVCs and ACs (p ϭ .35). CVC-PQC or AC-PQC was observed for 42 of 212 patients. CVC-PQC was ob- served for 26 patients (12.3%) and AC- PQC for 22 patients (10.4%; p ϭ .54). The incidence density of PQC per patient was 10.7 per 1,000 days of CVC use and 8.9 per 1,000 days of AC use (p ϭ .31). SAPS Figure 1. Proportion of central venous catheters and arterial catheters for which quantitative cultures II was 50.9 Ϯ 22.0 for the 42 patients were negative.

1278 Crit Care Med 2005 Vol. 33, No. 6 Table 3. Incidence of cultured microorganisms

Microorganism No. of CVC Cultures No. of AC Cultures mong severely ill

Gram-positive cocci 28 23 patients with both Staphylococcus epidermidis 11 12 12central venous and Enterococcus species 3 2 A Other 3 7 arterial catheters, the epide- Gram-negative bacilli 14 4 Pseudomonas aeruginosa 70miology of positive quantita- Enterobacter species 7 4 Total 42 27 tive cultures of the catheters CVC, central venous catheter; AC, arterial catheter. is comparable when the same infection control mea- and CVCs are never used for drawing reports are of randomized trials assessing blood samples. the risk of infection in relation to inser- sures are used for their in- To our knowledge, our work involves tion site (10), routine changing of cathe- sertion and maintenance. the largest series of ACs analyzed by a ters (22), use of antiseptic solutions (4), quantitative microbiological technique. or hygiene precautions on insertion (7). We chose to use the quantitative culture These studies include catheterizations method of Brun-Buisson (17) for the mi- via the radial (4, 5, 7, 9–11), femoral (4, crobiological diagnosis of CVC and AC 6, 10, 11), or dorsalis pedis (5, 7) routes. both types of catheter. Only Wester et infections because it has the advantage of The duration of catheter use varies be- al. (6) have studied jointly arterial and analyzing the intraluminal and extralu- tween 4 and 16 days. Some study reports venous catheterization in the same pa- minal portions of the catheter. Using a give no details on the culture techniques tients, but they specifically studied vascu- diagnostic threshold to define PQC makes used (9, 10, 21). The varied nature of lar routes used for continuous arterio- it possible to distinguish contamination these reports probably accounts for the venous hemodiafiltration, and the from colonization. The technique has wide discrepancies in the frequency of proportion of patients lost to follow-up never been tested with ACs in validation infection, with cumulative incidence was high. In most studies, catheter infec- studies; thus, we used it by extension to ranging between 0.4% and 43% and in- tion rates are more frequently observed define PQC. cidence density between 5 and 32 per in the most severely ill patients (24). In The incidence density of PQC of CVCs 1,000 days of catheter use (4, 5, 9, 23). In our study, patients with CVC-PQC or AC- in our study (12.0 per 1,000 days of cath- our study, cumulative incidence was PQC did not have higher SAPS II than eter use) is close to that reported by Ri- 7.7% and incidence density was 9.3 per patients without CVC-PQC or AC-PQC. jnders et al. (18) in a systematic review of 1,000 days of catheter use. The duration This could be related to the case-mix of reports on CVC-related infections pub- of arterial catheterization is shorter in our study population, which comprised lished between 1990 and 2002 (13.5 per our study than in all others reported ex- only patients who had both CVC and AC 1,000 days of catheter use). The fre- cept that of Martin et al. (5). This is placement for Ͼ48 hrs. On the basis of quency of PQC of CVCs found in our probably due to the specificity of our the inclusion criteria of the study, our study was close to that observed by our study population, which underwent both patient population was a subset of very group in a previous work (13). In agree- venous and arterial catheterization. Like severely ill patients, as demonstrated by ment with other studies, we found fewer most authors, we observed no difference the SAPS II values, the long ICU stay PQCs when the CVC was inserted via the in the frequency of PQC of ACs between (median, 10 days), and the high ICU subclavian route than via the internal radial and femoral insertion sites (2, 10). mortality rate (33%). The rates of cath- jugular or femoral routes (3, 19, 20), and In addition, in our study we found no eter infectious complications may be we observed no difference in PQCs related differences in AC-PQC between the fem- different in ICU populations who have a to the jugular vs. femoral insertion sites oral and brachial sites (p ϭ .69) or the lesser severity of illness, a shorter (3). As in most other studies, Gram- femoral and upper extremity sites (p ϭ positive cocci were the germs most com- .63). length of stay, and/or just one of the monly isolated in the PQCs of CVCs, with The microorganisms isolated in the two catheters. coagulase-negative staphylococci being PQCs of ACs in our study did not differ The number of cases of AC-related predominant. from those usually found. As with CVC bacteremia in our study was low and There have been few studies of AC- cultures, Gram-positive cocci were more comparable to that in most other re- related infections. In addition, it is diffi- common than Gram-negative bacilli, and ported studies (5, 7, 10, 25). The number cult to compare the findings because of among the Gram-positive cocci, coagu- of cases of CVC-related bacteremia (one the differences in study design, popula- lase-negative staphylococci were predom- for 308 CVCs) was similar to that in a tions studied, duration of catheter place- inant. previous study in which we found two ment, techniques of microbiological Our study is original in that it takes instances of CRB among 230 CVC recip- analysis, and the way in which results are into account the severity of the patients’ ients (13). No conclusion can be drawn expressed. Some study reports are purely condition in comparing the PQC rates of about CRB because of the small incidence descriptive (5, 6, 9, 11, 21), whereas other CVC and AC, because all patients had of bacteremia.

Crit Care Med 2005 Vol. 33, No. 6 1279 CONCLUSIONS 7. Rijnders BJ, Van Wijngaerden E, Wilmer A, Omega system. Intensive Care Med 1998; 24: et al: Use of full sterile barrier precautions 582–589 In a subgroup of severely ill ICU pa- during insertion of arterial catheters: A ran- 17. Brun-Buisson C, Abrouk F, Legrand P, et al: tients who have both CVCs and ACs domized trial. Clin Infect Dis 2003; 36: Diagnosis of central venous catheter-related placed, when the same infection control 743–748 sepsis. Critical level of quantitative tip cul- procedures are applied for insertion and 8. Gardner RM, Schwartz R, Wong HC, et al: tures. Arch Intern Med 1987; 147:873–877 maintenance, the epidemiology of PQCs Percutaneous indwelling radial- cathe- 18. Rijnders BJ, Van Wijngaerden E, Peetermans related to the two types of catheter is ters for monitoring cardiovascular function: WE: Catheter-tip colonization as a surrogate comparable. Prospective study of the risk of end point in clinical studies on catheter- and infection. N Engl J Med 1974; 290: related bloodstream infection: how strong is 1227–1231 the evidence? Clin Infect Dis 2002; 35: ACKNOWLEDGMENT 9. Frezza EE, Mezghebe H: Indications and 1053–1058 We thank Jeffrey Watts for help in complications of arterial catheter use in sur- 19. Merrer J, De Jonghe B, Golliot F, et al: preparing the manuscript. gical or medical intensive care units: analysis French Catheter Study Group in Intensive of 4932 patients. Am Surg 1998; 64:127–131 Care. Complications of femoral and subcla- 10. Thomas F, Burke JP, Parker J, et al: The risk vian venous catheterization in critically ill REFERENCES of infection related to radial vs femoral sites patients: A randomized controlled trial. for arterial catheterization. Crit Care Med JAMA 2001; 286:700–707 1. Band JD, Maki DG: Infections caused by ar- 1983; 11:807–812 20. Raad I, Darouiche R, Dupuis J, et al: Central terial catheters used for hemodynamic mon- itoring. Am J Med 1979; 67:735–741 11. Thomas F, Orme JF Jr, Clemmer TP, et al: A venous catheters coated with minocycline 2. Scheer B, Perel A, Pfeiffer UJ: Clinical review: prospective comparison of arterial catheter and rifampin for the prevention of catheter- complications and risk factors of peripheral blood and catheter-tip cultures in critically related colonization and bloodstream infec- arterial catheters used for hemodynamic ill patients. Crit Care Med 1984; 12:860–862 tions: A randomized, double-blind trial. The monitoring in anaesthesia and intensive care 12. Samsoondar W, Freeman JB, Coultish I, et al: Texas Medical Center Catheter Study Group. medicine. Crit Care 2002; 6:199–204 Colonization of intravascular catheters in the Ann Intern Med 1997; 127:267–274 3. McGee DC, Gould MK: Preventing complica- intensive care unit. Am J Surg 1985;149: 21. Singh S, Nelson N, Acosta I, et al: Catheter tions of central venous catheterisation. 730–732 colonization and bacteremia with pulmonary N Engl J Med 2003; 348:1123–1133 13. Souweine B, Traore O, Aublet-Cuvelier B, et and arterial catheters. Crit Care Med 1982; 4. Mimoz O, Pieroni L, Lawrence C, et al: Pro- al: Dialysis and central venous catheter in- 10:736–739 spective, randomized trial of two antiseptic fections in critically ill patients: Results of a 22. Norwood SH, Cormier B, McMahon NG, et al: solutions for prevention of central venous or prospective study. Crit Care Med 1999; 27: Prospective study of catheter-related infec- arterial catheter colonization and infection 2394–2398 tion during prolonged arterial catheteriza- in intensive care unit patients. Crit Care Med 14. Vincent JL, Moreno R, Takala J, et al: The tion. Crit Care Med 1988; 16:836–839 1996; 24:1818–1823 SOFA (Sepsis-related Organ Failure Assess- 23. Raad I, Umphrey J, Khan A, et al: The dura- 5. Martin C, Saux P, Papazian L, et al: Long- ment) score to describe / tion of placement as a predictor of peripheral term arterial cannulation in ICU patients us- failure. On behalf of the Working Group on and pulmonary arterial catheter infections. ing the radial artery or dorsalis pedis artery. Sepsis-Related Problems of the European So- J Hosp Infect 1993; 23:17–26 Chest 2001; 119:901–906 ciety of . Intensive 24. Girou E, Pinsard M, Auriant I, et al: Influence 6. Wester JP, de Koning EJ, Geers AB, et al: Care Med 1996; 22:707–710 of the severity of illness measured by the Analysis of Renal Replacement Therapy in 15. Le Gall JR, Lemeshow S, Saulnier F: A new Simplified Acute Physiology Score (SAPS) on the Seriously Ill (ARTIS) Investigators: Cath- Simplified Acute Physiology Score (SAPS II) occurrence of nosocomial infections in ICU eter replacement in continuous arterio- based on a European/North American multi- patients. J Hosp Infect 1996; 34:131–137 venous hemodiafiltration: The balance be- center study. JAMA 1993; 270:2957–2963 25. Leroy O, Billiau V, Beuscart C, et al: Noso- tween infectious and mechanical 16. Sznajder M, Leleu G, Buonamico G, et al: comial infections associated with long-term complications. Crit Care Med 2002; 30: Estimation of direct cost and resource allo- radial artery cannulation. Intensive Care 1261–1266 cation in intensive care: correlation with Med 1989; 15:241–246

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