【颠覆观点】插管位置对CRBSI无统计学意义的差异
本帖最后由 蓝鱼o_0 于 2012-8-8 11:02 编辑Crit Care Med. 2012 Aug;40(8):2479-85
The risk of catheter-related bloodstream infection with femoral venous catheters as compared to subclavian and internal jugular venous catheters: A systematic review of the literature and meta-analysis*.Marik PE, Flemmer M, Harrison W.
SourceFrom the Divisions of Pulmonary and Critical Care Medicine (PEM) and General Internal Medicine (MF), Eastern Virginia Medical School, Norfolk, VA; and Welsh Healthcare Associated Infection Program (WH), Public Health Wales, Cardiff, Wales.
AbstractBACKGROUND: : Catheter-related bloodstream infections are an important cause of morbidity and mortality in hospitalized patients. Current guidelines recommend that femoral venous access should be avoided to reduce this complication (1A recommendation). However, the risk of catheter-related bloodstream infections from femoral as compared to subclavian and internal jugular venous catheterization has not been systematically reviewed.
OBJECTIVE: : A systematic review of the literature to determine the risk of catheter-related bloodstream infections related to nontunneled central venous catheters inserted at the femoral site as compared to subclavian and internal jugular placement.
DATA SOURCES: : MEDLINE, Embase, Cochrane Register of Controlled Trials, citation review of relevant primary and review articles, and an Internet search (Google).
STUDY SELECTION: : Randomized controlled trials and cohort studies that reported the frequency of catheter-related bloodstream infections (infections per 1,000 catheter days) in patients with nontunneled central venous catheters placed in the femoral site as compared to subclavian or internal jugular placement.
DATA EXTRACTION: : Data were abstracted on study design, study size, study setting, patient population, number of catheters at each insertion site, number of catheter-related bloodstream infections, and the prevalence of deep venous thrombosis. Studies were subgrouped according to study design (cohort and randomized controlled trials). Meta-analytic techniques were used to summarize the data.
DATA SYNTHESIS: : Two randomized controlled trials (1006 catheters) and 8 cohort (16,370 catheters) studies met the inclusion criteria for this systematic review. Three thousand two hundred thirty catheters were placed in the subclavian vein, 10,958 in the internal jugular and 3,188 in the femoral vein for a total of 113,652 catheter days. The average catheter-related bloodstream infections density was 2.5 per 1,000 catheter days (range 0.6-7.2). There was no significant difference in the risk of catheter-related bloodstream infections between the femoral and subclavian/internal jugular sites in the two randomized controlled trials (i.e., no level 1A evidence). There was no significant difference in the risk of catheter-related bloodstream infections between the femoral and subclavian sites. The internal jugular site was associated with a significantly lower risk of catheter-related bloodstream infections compared to the femoral site (risk ratio 1.90; 95% confidence interval 1.21-2.97, p = .005, I = 35%). This difference was explained by two of the studies that were statistical outliers. When these two studies were removed from the analysis there was no significant difference in the risk of catheter-related bloodstream infections between the femoral and internal jugular sites (risk ratio 1.35; 95% confidence interval 0.84-2.19, p = 0.2, I = 0%). Meta-regression demonstrated a significant interaction between the risk of infection and the year of publication (p = .01), with the femoral site demonstrating a higher risk of infection in the earlier studies. There was no significant difference in the risk of catheter-related bloodstream infection between the subclavian and internal jugular sites. The risk of deep venous thrombosis was assessed in the two randomized controlled trials. A meta-analysis of this data demonstrates that there was no difference in the risk of deep venous thrombosis when the femoral site was compared to the subclavian and internal jugular sites combined. There was, however, significant heterogeneity between studies.
CONCLUSIONS: : Although earlier studies showed a lower risk of catheter-related bloodstream infections when the internal jugular was compared to the femoral site, recent studies show no difference in the rate of catheter-related bloodstream infections between the three sites.
看到这个信息我很高兴，因为我的监测显示无差异！
但这个Meta的证据是2项随机对照研究和8个队列研究，不知从证据级别上论证，是否可信？请教蓝鱼？ 本帖最后由 蓝鱼o_0 于 2012-8-8 10:47 编辑
缭绕 发表于 2012-8-8 10:38 http://bbs.sific.com.cn/static/image/common/back.gif
看到这个信息我很高兴，因为我的监测显示无差异！
但这个Meta的证据是2项随机对照研究和8个队列研究，不知 ...
队列研究的证据已经是分析流行病学中很强的证据了，因为是由暴露到结局，所以结果相对可信。
但是所有纳入研究的质量还需要进行更细致细致的考证。
When these two studies were removed from the analysis there was no significant difference in the risk of catheter-related bloodstream infections between the femoral and internal jugular sites (risk ratio 1.35; 95% confidence interval 0.84–2.19, p = 0.2, I2 = 0%).
根据这个结果，能够显示差异很不显著，且无异质性。不过仅仅两篇随机对照研究支持，尚需要进一步验证。
但队列研究的结果已经很显著了，就是股静脉插管与锁骨下静脉插管无差异。
本帖最后由 蓝鱼o_0 于 2012-8-8 10:52 编辑
股静脉插管与锁骨下无统计学意义的差别，在这张图上非常显著。
有8篇队列研究的结果，且样本量也不算小了2152/1993。使用的模型是随机效应模型。异质性极低 《25%.
也许有人会有疑问，为什么无显著异质性，仍然选择随机效应模型（RE）。
这里不得不提到随机效应模型和固定效应模型的差异。目前认为，随机效应模型的可信区间较相同条件下固定效应模型要宽。
即特异度更高。如果在这种情况下，效果仍然有意义，那么我们认为结论可信度较高。
反之，则需要好好斟酌。
对多种设计合并后的森林图，现在医院感染流行病和统计学者都倾向于使用随机效应模型，以验证结果的稳定性。
非常新颖的文献，非常新颖的结论。
大体瞄了一眼摘要，个人突然性的一个观点：在CRBSI感染率已经很低的情况下，无论用何种方法再进一步的预防，基本是不会有太大的差异的，因为这个感染率已经到了不可能改变的极限了（根据作者的医院区域和水平）；举例来说：某个医院CRBSI的感染率为千日导管2.5，就是将目前世界上所有的循证预防措施都用上，千日导管2.5的感染率也有可能不会有大的改变（毕竟这个感染还与患者自身的疾病和个体免疫力有关系的），当然好的医院完全可以做到“零容忍”，这就另当别论了。 未发现统计学意义的出版偏倚。
这里有个思考题，为什么漏斗图没有显示两条线呢？{:1_9:}
本帖最后由 蓝鱼o_0 于 2012-8-8 11:06 编辑
股静脉与颈内静脉比较结果显示，股静脉插管可以显著增加CR-BSI的发病风险，换言之，颈静脉插管可以显著降低CRBSI的发病风险（与文中作者表述一致）。
非常有意思，这篇研究做了meta-regression。来解释异质性。
以往我们都忽略了这个问题，其实也是有原因的，因为纳入的研究数目比较少（N<10）
在这篇研究中，有2篇RCT和8篇队列研究纳入。
Meta-regression demonstrated a significant interaction between the risk of infection and the year of publication
(p = .01)
非常有趣的是，感染率与出版的年份之间存在统计学意义的交互作用。{:1_12:}
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这个的影响因子有多高啊？初步瞟了一样，如果说影响力很大的话，结果很可信，那不是将我们以前的东西都推翻了啊？？然后他的样本量和这个研究的结果又没有关系？如果增大样本能得出这个结果吗？ toto 发表于 2012-8-8 15:17 static/image/common/back.gif
这个的影响因子有多高啊？初步瞟了一样，如果说影响力很大的话，结果很可信，那不是将我们以前的东西都推 ...
影响因子6.33.
2008年事6.5左右。基本维持在6分。危重病专业杂志，侧重临床。也会为较好的基础研究提供机会。 颠覆了以前的东西，看来指南要重写了！{:1_12:} 蓝鱼o_0 发表于 2012-8-8 11:14 static/image/common/back.gif
非常有意思，这篇研究做了meta-regression。来解释异质性。
以往我们都忽略了这个问题，其实也是有原因的 ...
RCT无疑是最好的研究方法，但在一般情况下，RCT很难做到，退而求次，队伍研究的结论也是可信性较高的，近次于RCT。
这里提一个问题，这篇文章一共纳入了10篇文章，如果多纳入一些文章，加大样本量，又将得出什么结论？我们再进行一次系统评价和meta分析，其意义又如何？引用相同的文献，得出相反的结论还是有例子的。因此我们能否进行一些深入的探讨？我们该用什么样的眼光来看待异质性？如何看待随机效应模型和固定效应模型的差异，都是值得我们深思。对于血流感染就用这一篇文章，来得出结论，我认为为时过早。希望大家对这些问题进行进一步的探讨！ 非常有意思的研究，谢谢蓝鱼超版的分享 看来还是应了那句：实践是检验真理的唯一标准！目前，我们正在做这方面的目标性监测。期待不一样的结果！ 大家都是统计高手！都想从循证的观点得出数字化的结论，其实这个问题在mate 分析培训班上胡教授已提过。
我们不妨单从理论上考虑，假设一个人从头到脚都是无菌的，那从哪个部位穿刺又会有什么区别呢！？
现实的研究却是一个个活生生的不同的病人，对于引起导管相关血流感染的影响因子可能很多，比如病人机体免疫力，比如无菌操作个体差异性，比如一般人似乎都是腹股沟处比锁骨上容易沾染细菌的，比如合并糖尿病，肿瘤等等。如果你能排除所有影响因素，那结果就是一样的。
相信随着无菌操作及医学水平的越来越深入化，科学化，原指南可能就是个错误！
这样的例子在医学界是很常见的，科学总在发展，观点总在更新！不是吗！
新的信息：股静脉导管没有增加导管相关血流感染的危险
本帖最后由 桂花香 于 2013-1-27 10:36 编辑关于导管相关血流感染的预防，普遍认为，导管穿刺点应首先锁骨下静脉，尽量不用股静脉，因为股静脉穿刺会增加血流感染的危险，但是这里有一篇META分析，提示股静脉穿刺与锁骨下、颈静脉穿刺的BSI危险无差异
Upon Further Review: Femoral Venous Catheters Do Not Increase Risk of Catheter-Related Bloodstream Infection.
Watkins, Richard R. MD, MS, FACP
Infectious Disease Alert. 32(4):39-40, January 2013.
AN: 00475502-201301000-00002.
AB SYNOPSIS: In a meta-analysis, investigators found that recent studies show no difference in the risk of catheter-related bloodstream infections between internal jugular, subclavian, and femoral sites. Older studies had a lower risk for the internal jugular site compared to the femoral site. SOURCE: Marik PE, et al. The risk of catheter-related bloodstream infection with femoral venous catheters as compared to subclavian and internal jugular venous catheters: A systemic review of the literature and meta-analysis. Crit Care Med 2012;40(8):2479-85. (C) 2013 AHC Media LLC.
一直说要用循证医学来说服临床，但我们觉得是很困难的，就拿导管相关性血流感染，我们麻醉科为方便一直是放在股静脉，对ICU我们做目标性监测，但没有对全院开展，而每年的全院医院感染监测也没有导管相关性血流感染的病例。倒是血透室外院转来我院放置的临时性颈部造瘘发现感染2例。所以要说服麻醉科改放颈部或锁骨下静脉拿不出自己医院的。 感谢楼主提供的新信息，能不能把这篇股静脉导管没有增加导管相关血流感染的危险META分析用中文翻译贴出来呢？{:1_17:} 如果有这样的报道与我院ICU的意见不谋而合，早在好几年前，我们ICU没有执行锁骨下静脉穿刺时，大部分是股静脉，发生感染很少，他们认为最易感染是颈内静脉，{:1_9:}
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