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Central venous catheter replacement strategies: A systematic review of the literature

Cook, Deborah MD, FRCPC, MSc(Epid); Randolph, Adrienne MD, MSc; Kernerman, Phillip MD; Cupido, Cynthia MD; King, Derek BMath; Soukup, Clara MD; Brun-Buisson, Christian MD

Special Article

Objective  To evaluate the effect of guidewire exchange and new-site replacement strategies on the frequency of catheter colonization and infection, catheter-related bacteremia, and mechanical complications in critically ill patients.

Data Sources  We searched for published and unpublished research by means of MEDLINE and Science Citation Index, manual searching of Index Medicus, citation review of relevant primary and review articles, review of personal files, and contact with primary investigators.

Study Selection  From a pool of 151 randomized, controlled trials on central venous catheter management, we identified 12 relevant randomized trials of catheter replacement over a guidewire or at a new site.

Data Extraction  In duplicate and independently, we abstracted data on the population, intervention, outcome, and methodologic quality.

Data Synthesis  As compared with new-site replacement, guidewire exchange is associated with a trend toward a higher rate of catheter colonization (relative risk 1.26, 95% confidence interval 0.87 to 1.84), regardless of whether patients had a suspected infection. Guidewire exchange is also associated with trends toward a higher rate of catheter exit-site infection (relative risk 1.52, 95% confidence interval 0.34 to 6.73) and catheter-related bacteremia (relative risk 1.72, 95% confidence interval 0.89 to 3.33). However, guidewire exchange is associated with fewer mechanical complications (relative risk 0.48, 95% confidence interval 0.12 to 1.91) relative to new-site replacement. Exchanging catheters over guidewires or at new sites every 3 days is not beneficial in reducing infections, compared with catheter replacement on an as-needed basis.

Conclusions  Guidewire exchange of central venous catheters may be associated with a greater risk of catheter-related infection but fewer mechanical complications than new-site replacement. More studies on scheduled vs. as-needed replacement strategies using both techniques are warranted. If guidewire exchange is used, meticulous aseptic technique is necessary. (Crit Care Med 1997; 25:1417-1424)

From the Departments of Medicine (Drs. Cook, Cupido, and Soukup) and Clinical Epidemiology and Biostatistics (Dr. Cook and Mr. King), McMaster University, Hamilton, ON, Canada; the Departments of Pediatrics and Anesthesia (Dr. Randolph), Harvard University, Boston, MA; the Department of Critical Care (Dr. Kernerman), University of Toronto, Toronto, ON, Canada; and the Department of Intensive Care, Hopital Henri Mondor (Dr. Brun-Buisson), Creteil, France.

Supported, in part, by the Ontario Ministry of Health.

Address requests for reprints to: Deborah J. Cook, MD, Division of Critical Care, Department of Medicine, St. Joseph's Hospital, 50 Charlton Avenue East, Hamilton, ON, Canada L8N 4A6.

© Williams & Wilkins 1997. All Rights Reserved.