title: Predictors of unattempted central venous catheterization in septic patients eligible for early goal-directed therapy.
abstract: BACKGROUND
  Central venous catheterization (CVC) can be an important component of the management of patients with severe sepsis and septic shock. CVC, however, is a time- and resource-intensive procedure associated with serious complications. The effects of the absence of shock or the presence of relative contraindications on undertaking central line placement in septic emergency department (ED) patients eligible for early goal-directed therapy (EGDT) have not been well described. We sought to determine the association of relative normotension (sustained systolic blood pressure >90 mmHg independent of or in response to an initial crystalloid resuscitation of 20 mL/kg), obesity (body mass index [BMI] ≥30), moderate thrombocytopenia (platelet count <50,000 per μL), and coagulopathy (international normalized ratio ≥2.0) with unattempted CVC in EGDT-eligible patients.
  
  
  METHODS
  This was a retrospective cohort study of 421 adults who met EGDT criteria in 5 community EDs over a period of 13 months. We compared patients with attempted thoracic (internal jugular or subclavian) CVC with those who did not undergo an attempted thoracic line. We also compared patients with any attempted CVC (either thoracic or femoral) with those who did not undergo any attempted central line. We used multivariate logistic regression analysis to calculate adjusted odd ratios (AORs).
  
  
  RESULTS
  In our study, 364 (86.5%) patients underwent attempted thoracic CVC and 57 (13.5%) did not. Relative normotension was significantly associated with unattempted thoracic CVC (AOR 2.6 95% confidence interval [CI], 1.6-4.3), as were moderate thrombocytopenia (AOR 3.9; 95% CI, 1.5-10.1) and coagulopathy (AOR 2.7; 95% CI, 1.3-5.6). When assessing for attempted catheterization of any central venous site (thoracic or femoral), 382 (90.7%) patients underwent attempted catheterization and 39 (9.3%) patients did not. Relative normotension (AOR 2.3; 95% CI, 1.2-4.5) and moderate thrombocytopenia (AOR 3.9; 95% CI, 1.5-10.3) were significantly associated with unattempted CVC, whereas coagulopathy was not (AOR 0.6; 95% CI, 0.2-1.8). Obesity was not significantly associated with unattempted CVC, either thoracic in location or at any site.
  
  
  CONCLUSIONS
  Septic patients eligible for EGDT with relative normotension and those with moderate thrombocytopenia were less likely to undergo attempted CVC at any site. Those with coagulopathy were also less likely to undergo attempted thoracic central line placement. Knowledge of the decision-making calculus at play for physicians considering central venous catheterization in this population can help inform physician education and performance improvement programs.
authors.affiliation: The Permanente Medical Group, Oakland, California ; Kaiser Permanente Roseville Medical Center, Roseville, California.
authors.forename: David R
authors.initials: DR
authors.lastname: Vinson
authors.affiliation: The Permanente Medical Group, Oakland, California ; Kaiser Permanente San Rafael Medical Center, San Rafael, California.
authors.forename: Dustin W
authors.initials: DW
authors.lastname: Ballard
authors.affiliation: Loma Linda University School of Medicine, Loma Linda, California.
authors.forename: Matthew D
authors.initials: MD
authors.lastname: Stevenson
authors.affiliation: The Permanente Medical Group, Oakland, California ; Kaiser Permanente Oakland Medical Center, Oakland, California.
authors.forename: Dustin G
authors.initials: DG
authors.lastname: Mark
authors.affiliation: Kaiser Permanente Division of Research, Oakland, California.
authors.forename: Mary E
authors.initials: ME
authors.lastname: Reed
authors.affiliation: Kaiser Permanente Division of Research, Oakland, California.
authors.forename: Adina S
authors.initials: AS
authors.lastname: Rauchwerger
authors.affiliation: The Permanente Medical Group, Oakland, California ; Kaiser Permanente South San Francisco Medical Center, South San Francisco, California.
authors.forename: Uli K
authors.initials: UK
authors.lastname: Chettipally
authors.affiliation: The Permanente Medical Group, Oakland, California ; Kaiser Permanente South Sacramento Medical Center, Sacramento, California.
authors.forename: Steven R
authors.initials: SR
authors.lastname: Offerman
mesh_terms: D000368:Aged; D002405:Catheterization, Central Venous / Q000706:statistics & numerical data*; D002985:Clinical Protocols; D015331:Cohort Studies; D004636:Emergency Service, Hospital; D005260:Female; D006801:Humans; D008297:Male; D008875:Middle Aged; D010347:Patient Care Planning; D018805:Sepsis / Q000628:therapy*