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Vascular access for renal replacement therapy among 459 critically ill patients: a pragmatic analysis of the randomized AKIKI trial

Nicolas Benichou 1, 2, 3 Saïd Lebbah 4 David Hajage 4, 5 Laurent Martin-Lefèvre 6 Bertrand Pons 7 Eric Boulet 8 Alexandre Boyer 9 Guillaume Chevrel 10 Nicolas Lerolle 11 Dorothée Carpentier 12 Nicolas de Prost 13, 14 Alexandre Lautrette 15 Anne Bretagnol 16 Julien Mayaux 17 Saad Nseir 18 Bruno Megarbane 19, 20 Marina Thirion 21 Jean-Marie Forel 22 Julien Maizel 23 Hodane Yonis 24 Philippe Markowicz Guillaume Thiery 7 Frederique Schortgen 25 Florence Tubach 4, 5 Jean-Damien Ricard 26, 27 Didier Dreyfuss 27, 2, 3 Stéphane Gaudry 2, 3, 28
Abstract : Background: Vascular access for renal replacement therapy (RRT) is routine question in the intensive care unit. Randomized trials comparing jugular and femoral sites have shown similar rate of nosocomial events and catheter dysfunction. However, recent prospective observational data on RRT catheters use are scarce. We aimed to assess the site of RRT catheter, the reasons for catheter replacement, and the complications according to site in a large population of critically ill patients with acute kidney injury. Patients and methods: We performed an ancillary study of the AKIKI study, a pragmatic randomized controlled trial, in which patients with severe acute kidney injury (KDIGO 3 classification) with invasive mechanical ventilation, catecholamine infusion or both were randomly assigned to either an early or a delayed RRT initiation strategy. The present study involved all patients who underwent at least one RRT session. Number of RRT catheters, insertion sites, factors potentially associated with the choice of insertion site, duration of catheter use, reason for catheter replacement, and complications were prospectively collected. Results: Among the 619 patients included in AKIKI, 462 received RRT and 459 were finally included, with 598 RRT catheters. Femoral site was chosen preferentially (n = 319, 53%), followed by jugular (n = 256, 43%) and subclavian (n = 23, 4%). In multivariate analysis, continuous RRT modality was significantly associated with femoral site (OR = 2.33 (95% CI (1.34-4.07), p = 0.003) and higher weight with jugular site [88.9 vs 83.2 kg, OR = 0.99 (95% CI 0.98-1.00), p = 0.03]. Investigator site was also significantly associated with the choice of insertion site (p = 0.03). Cumulative incidence of catheter replacement did not differ between jugular and femoral site [sHR 0.90 (95% CI 0.64-1.25), p = 0.67]. Catheter dysfunction was the main reason for replacement (n = 47), followed by suspected infection (n = 29) which was actually seldom proven (n = 4). No mechanical complication (pneumothorax or hemothorax) occurred. Conclusion: Femoral site was preferentially used in this prospective study of RRT catheters in 31 French intensive care units. The choice of insertion site depended on investigating center habits, weight, RRT modality. A high incidence of catheter infection suspicion led to undue replacement.
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Submitted on : Friday, April 9, 2021 - 2:17:52 PM
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Nicolas Benichou, Saïd Lebbah, David Hajage, Laurent Martin-Lefèvre, Bertrand Pons, et al.. Vascular access for renal replacement therapy among 459 critically ill patients: a pragmatic analysis of the randomized AKIKI trial. Annals of Intensive Care, SpringerOpen, 2021, 11 (1), pp.56. ⟨10.1186/s13613-021-00843-3⟩. ⟨hal-03194284⟩



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