背景:隧道式中心静脉导管通常用于没有功能性永久性血管通路的患者的透析。在紧急情况下,一个非隧道,临时中心静脉导管通常用于立即透析。导管插入最关键的步骤是静脉穿刺,这通常是延长干预时间和与手术相关的不良事件的主要原因。为避免在放置更永久的隧道导管时发生此关键步骤,可以考虑对以前放置的临时交换。在本文中,我们提出了一种具有单独访问站点的改进的交换方法。方法:在对前瞻性数据库的回顾性分析中,我们检查了这种改进的技术是否不劣于从头应用。因此,我们纳入了2018年3月至2023年3月在我们的研究中心接受首根隧道式透析导管的所有396例患者.在这些中,143例患者接受了改良方法,253例接受了标准的从头超声引导穿刺和插入。然后,两组的结果,包括不良事件和感染,通过非参数检验和多变量逻辑回归进行比较。结果:两组,种植100%成功。根据CDC标准,18例因感染而进行导管外植术是必要的,两组之间没有差异(5.0%vs.4.4%p=0.80)。每100天的感染率为0.113。对照组为0.106,具有可比的细菌谱。总共12根导管(3根与9)由于介入周围的并发症而不得不移除。早期感染是研究组2例(1.3%)和对照组5例(1.9%)的原因。仅在对照组中有2例发生导管完全错位。通过多变量逻辑回归校正潜在的混杂因素后,并发症发生率没有显着差异(校正后的比值比,aOR=0.53,95%CI=0.14-2.03,p=0.351),但基于平均治疗效果-1.7%的总体估计风险降低,有利于研究组。结论:本研究表明,导管交换不会导致比从头放置更多的感染;因此,这是一个可行的方法。此外,通过交换完全避免了静脉穿刺后排除气胸的置换和对照胸部X线检查。这种方法产生的感染率比以前的报告低得多:1.3%,而在所有现有的汇总研究中为2.7%。所提出的方法似乎优于现有的切换方法。总的来说,交换也可以帮助保存静脉以备将来使用,因为使用相同的颈静脉。
Background: Tunneled central venous catheters are commonly used for dialysis in patients without a functional permanent vascular access. In an emergent setting, a non-tunneled, temporary central venous
catheter is often placed for immediate dialysis. The most critical step in the
catheter insertion is venipuncture, which is often a major cause for longer intervention times and procedure-related adverse events. To avoid this critical step when placing a more permanent tunneled
catheter, an exchange over a previously placed temporary one can be considered. In this paper, we present a modified switching approach with a separate access site. Methods: In this retrospective analysis of a prospective database, we examined whether this modified technique is non-inferior to a de novo application. Therefore, we included all 396 patients who received their first tunneled dialysis
catheter at our site from March 2018 to March 2023. Out of these, 143 patients received the modified approach and 253 the standard de novo ultrasound-guided puncture and insertion. Then, the outcomes of the two groups, including adverse events and infections, were compared by nonparametric tests and multivariable logistic regression. Results: In both groups, the implantations were 100% successful. Catheter explantation due to infection according to CDC criteria was necessary in 18 cases, with no difference between the groups (5.0% vs. 4.4% p = 0.80). The infection rate per 100 days was 0.113 vs. 0.106 in the control group, with a comparable spectrum of bacteria. A total of 12 catheters (3 vs. 9) had to be removed due to a periinterventional complication. An early-onset infection was the reason in two cases (1.3%) in the study group and five in the control group (1.9%). A total misplacement of the
catheter occurred in two cases only in the control group. After adjustment for potential confounders via multivariable logistic regression there was not a significant difference in the complication rate (adjusted odds ratio, aOR = 0.53, 95% CI = 0.14-2.03, p = 0.351) but an estimated decreased risk overall based on the average treatment effect of -1.7% in favor of the study group. Conclusions: The present study shows that a catheter exchange leads to no more infections than a de novo placement; hence, it is a feasible method. Moreover, misplacements and control chest X-rays to exclude pneumothorax after venipuncture were completely avoided by exchanging. This approach yields a much lower infection rate than previous reports: 1.3% compared to 2.7% in all existing aggregated studies. The presented approach seems to be superior to existing switching methods. Overall, an exchange can also help to preserve veins for future access, since the same jugular vein is used.