Effect of subcutaneous tunneling on internal jugular catheter-related sepsis in critically ill patients: a prospective randomized multicenter study.

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.