1. Routine replacement of CVC is not necessary JF Timsit MD

2. Scheduled change because of.... habits France 1994 U.K. 1996

3. Probability density function of infectious catheter complications Complication prob. (per cent/day) Duration (days) Stenzel JP- Crit Care Med 1989

4. 330 94 36 11 151 71 33 14 Incidence rates per 1000 days of catheter use Souweine B- Crit Care Med 1999; 27:2394

5. Old tunnel New tunnel Old catheter New catheter Sheretz ICAAC 1990

6. De novo vs replaced CVCs Bradley AD - Mayo Clin Proc 1996;71:838

8. CRI Hazards are not constant...

9. Pneumothorax Mediastinal hematoma Cardiac arythmia Brachial plexus injury Phrenic injury Cerebral air embolism Thrombosis Catheter fracture Arterial puncture Hemorrhage Cardiac tamponade Hemothorax Pleural effusion Subcutaneous emphysema Endocardial damage Myocardial perforation Endotracheal cuff perforation Arterial laceration

10. Complications of subclavian vein catheterization Misplacement Arterial puncture Pneumothorax Mediastinal hematoma More than one complic. N=824 49 (6%) 30 (3.7%) 12 (1.5%) 5 (0.6%) 16 (1.9%) Mansfield N Eng J Med 1994;331:1735

11. New site vs Guidewire exchange complications Cobb N. Eng J Med 1992; 327:1062 Pneumothorax Arythmia Suspected thrombosis Bleeding Colonization BSI New (n=76 Pts) 3 2 3 1 11 2 GWX (n=84 Pts) 3 2 0 15 6

12. New site vs Guidewire exchange (metaanalysis: 8 trials) Cook DJ Crit Care Med 1997;25:1417 Catheter colonization 1.26 [0.87-1.84] Catheter exit site infection1.52 [0.34-6.73] Catheter- related bacteremia1.72 [0.89-3.33]

13. Scheduled replacement of CVCs Randomized study –4 groups, factorial design –Replacement every 3 days vs as clinically indicated –New site vs guidewire exchange (GWX) ICU patients requiring CVC  3 days Colonization (Maki) Infections and mechanical complications 192 inclusions / 32 (17% excluded after randomization) Cobb N. Eng J Med 1992; 327:1062

14. Patients Cobb N. Eng J Med 1992; 327:1062 Med/surg Age APACHE II Malignant conditions Diabetes 3dys (n=35) 18/17 57 19 2 7 3dys/GWX (n=40) 21/19 59 19 2 6 Clin. (n=41) 20/21 55 18 5 7 Clin/GWX (n=35) 18/26 59 19 3 9

15. Catheters Cobb N. Eng J Med 1992; 327:1062 PAC/CVC SC/IJV 1st/2nd residents Total KT days Mean KT days/KT 3dys (n=109) 41/68 75/34 66/43 10 3 3dys/GWX (n=220) 109/111 79/147 139/81 17 3 Clin. (n=94) 43/51 37/74 56/38 13 6 Clin/GWX (n=100) 40/60 39/66 55/45 15 7 P 0.9 0.044 0.14 0.08 0.001

16. 3 days vs Clinically indicated complications Cobb N. Eng J Med 1992; 327:1062 Pneumothorax Arythmia Suspected thrombosis Bleeding Colonization BSI 3dys (n=75 Pts) 4 1 2 1 16 5 Clin. (n=85 Pts) 3 1 0 10 3

17. GWX (4 days) vs clinically indicated 150 patients / randomized/ 191 monolumen CVC 21 exclusions (11%) SAPS I N CVC CRI (/1000 CVC days) Colonization (>10 3 CFU/ml) (/1000 CVC days) Clinically N=75 15.8 111 3.7 GWX N=83 15.3 254 5.4 2.3 Berthelot: Presse Med 1997;26:1089

18. 122 patients, surgical ICU PA, Arterial or CVC for more than 7 days 3 groups, Change/ 7 days, 10 patients excluded Age APACHE II Violations Violations/catheter change GWX (n=41) 45 15.2 30 11 % PERC (n=32) 54 14.5 25 14 % NoChange (n=39) 52 14.4 31 21 % Eyer S - Crit Care Med 1990

19. GWX (n=41) 7 5 15% 4 6 1.8 + 0.2 PERC (n=32) 9 1 16% 5 7 3.5 + 0.5 NoChange (n=39) 0 1 13% 3 2 2.7 + 0.3 Catheter tip colonization (n) Subcutaneous seg.(n) % CRS CRS/1000 CVC days Mechanical compl. Nb puncture/patients

20. No change… because No evidence of increase in the hazard rate with time… Increased risk of mechanical complications Results of randomized controled study Results of meta-analysis Not recommended…

21. Recommendations More recent data suggest that the daily risk of infection remains constant and that routine changes of CVCs, without clinical indication, do not reduce the rate of catheter-related BSI... "Central venous.... catheters should be changed only when clinically indicated, for example, catheter malfunction, fever without clear source, or evidence of local catheter-related infection..... (Grade A evidence)" Saint S - Am J Med 1998;105:515 Federal register 60:187/ Wednesday Sept 27, 1995

22. GWX if:Malfunction Positive blood culture or sepsis New site if:Septic shock Skin site infection Remove useless CVCs.... Catheter exchange...

23. Routine catheter exchange..... Never!