Which central venous catheters have the highest rate of catheter-associated deep venous thrombosis: A prospective analysis of 2,128 catheter days in the surgical intensive care unit Darren Malinoski, MD, Tyler Ewing, Akash Bhakta, Randi Schutz, Bryan Imayanagita, Tamara Casas, Noah Woo, Daniel Margulies, MD, Cristobal Barrios, MD, Michael Lekawa, MD, Rex Chung, MD, Marko Bukur, MD, and Allen Kong, MD, Irvine, California BACKGROUND: Catheter-associated deep venous thromboses (CADVTs) are a common occurrence in the surgical intensive care unit (SICU), necessitating central venous catheter (CVC) removal and replacement. Previous studies evaluating risk factors for CADVT in SICU patients are limited, and most lack a true denominator of all CVC days. We sought to determine the true incidence of and risk factors for CADVT based on patient characteristics as well as CVC site, type, and duration of insertion. METHODS: The following data from all SICU patients in two urban Level I trauma centers were prospectively collected from 2009 to 2012: demographics, risk factors for DVT, CVC site/type/duration, and duplex results. Sites included the subclavian (SC), internal jugular (IJ), arm (for peripherally inserted central catheter [PICC] lines), and femoral. Types included multilumen (ML), introducer/hemodialysis (I/HD), and PICC. High-risk patients received weekly screening duplex examinations and a CADVT was defined as a DVT being detected on duplex with a CVC in place or within 7 days of removal. Rates of CADVTwere normalized per 1,000 CVC days, and independent predictors of CADVTwere determined using logistic regression. RESULTS: Data were complete for 184 patients, 354 CVCs, and 2,128 CVC days. Fifty-nine CADVTs were diagnosed in 28% of patients. Rates of CADVTwere 9 per 1,000 catheter days for SC, 61 for IJ (p G 0.01 vs. SC), 27 for arm (p G 0.01), 36 for femoral (p G 0.01), 22 for ML, 57 for I/HD (p G 0.01 vs. ML), and 27 for PICC (p = 0.24). After adjusting for patient risk factors, predictors of CADVT included the IJ and arm sites (odds ratio, 6.0 and 3.0 compared with SC) and the I/HD type (odds ratio, 2.6 compared with ML, all p G 0.05). CONCLUSION: The IJ and arm sites and I/HD type are associated with increased CADVT. These data may be used to determine the opti- mal site and type of CVC for insertion. (J Trauma Acute Care Surg. 2013;74: 454Y462. Copyright * 2013 by Lippincott Williams & Wilkins) LEVEL OF EVIDENCE: Prognostic/epidemiologic study, level III. KEY WORDS: Catheter-associated deep venous thrombosis; risk factors; central venous catheter; critical care. D eep venous thrombosis (DVT) and its progression to pulmonary embolism (PE) is a significant source of mor- bidity and mortality in the surgical intensive care unit (SICU). The insertion of a central venous catheter (CVC) is frequently indicated in critically ill patients and fulfills Virchow’s triad of risk for thromboembolism, namely, hypercoagulability, stasis, and venous injury. 1 As such, CVC placement has been cited as one of the most powerful predictors of DVT, with 55% to 72% of upper-extremity DVTs being associated with an indwelling central catheter, 2Y8 Risk factors for catheter-associated DVT (CADVT) are thought to include malignancy, recent trauma or surgery, his- tory of venous thromboembolism (VTE), older age, renal failure, and catheter location. 6,8Y14 CADVT has been commonly asso- ciated with the insertion of internal jugular CVCs (IJ, 42%), arm (27%), and femoral CVCs (22%). 12,13,15 In a multi-ICU ran- domized control trial, the subclavian (SC) vein was cited as the site with the lowest risk of thrombosis (2% vs. 22%) and catheter- associated infection (20% vs. 5%) compared with femoral. 12 A prospective observational study of ICU patients showed sig- nificantly lower CADVT rates in the SC compared with IJ (42% vs. 10%). 13 When examining CVC type, CADVT is most com- monly associated with multilumen catheters in SICU patients (46%). 5 Peripherally inserted central catheters (PICC) are asso- ciated with significantly more CADVT compared with other CVCs (27% vs. 10%). 15 Studies have reported rates of 4 to 8 CADVT per 1,000 catheter days in mixed patient populations. 11,15 Previous studies in surgical patients, however, have yet to report CADVT rates with a true denominator of all CVC days occurring in the SICU across all CVC locations (SC, IJ, arm, and femoral) and types. In addition, the optimal form of detection, prophylaxis, and treatment of CADVT has not been well established in a AAST 2012 PLENARY P APER J Trauma Acute Care Surg Volume 74, Number 2 454 Submitted: August 11, 2012, Revised: September 9, 2012, Accepted: October 18, 2012. From the Section of Surgical Critical Care, Portland Veterans Affairs Medical Center (D.Mal.), Portland, Oregon; School of Medicine, University of California (T.E.), Davis, Sacramento; Division of Trauma and Critical Care, University of California (R.S., B.I., N.W., C.B., M.L., A.K.), Irvine, California; Department of Surgery, Cedars-Sinai Medical Center (T.C., D.Mal., R.C., M.B.), Los Angeles, California; and Midwestern University (A.B.), Downers Grove, Illinois. This study was presented at the 71st Annual Meeting of the American Association for the Surgery of Trauma and Clinical Congress of Acute Care Surgery in Kauai, Hawaii, September 12Y15, 2012. Address for reprints: Darren J. Malinoski, MD, Section of Surgical Critical Care, Portland Veterans Affairs Medical Center, Oregon Health and Science University, PO Box 1034 / P3ANES, Portland, OR 97207; email: malinosk@ohsu.edu. DOI: 10.1097/TA.0b013e31827a0b2f Copyright © 2013 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.