The Arterial Line: A Significant Source of Blood Stream Infections

A recent systematic review & meta-analysis was just published in Critical Care Medicine this month looking at whether arterial lines are a significant source of catheter-related blood stream infections (CRBSIs).  Now, I’ll be the first to admit that this is a highly-debated topic – which makes it perfect for discussion….

So what did they find?  Well, after reviewing almost 50 studies, the authors concluded that a-lines are an under recognized and significantsource of CRBSIs.  Here is the breakdown:

• Incidence: In systematically cultured arterial catheters, the infection rate was 1.6 infections/1,000 catheter days which is similar to what has been reported for infections associated with short-term CVC’s.
• Location: Femoral a-lines are more likely than radial a-lines to be a source of a CRBSI. Femoral a-line CRBSIs occurred in 1.5% of all catheters (95% CI, 0.8–2.2%), which is higher than radial CRBSI, with a relative risk of infection 1.94 times greater than those placed at the radial site.
• Technique: Only one study specifically evaluated the impact of full barrier precautions versus using sterile gloves only for peripheral a-lines, and it did not find any significant difference in BSI. No study has evaluated the impact of maximal barrier precautions for femoral, axillary, and brachial arterial catheters.
• Dressing: The risk of infection was significantly decreased with the use of chlorhexidine-impregnated dressings (ex: BioPatch).

So I have to admit, up until recently I was a partial-barrier (perforated drape, sterile gloves only) guy primarily because I was always taught that a-lines rarely got infected (high flow, low risk of catheter contamination). However, over the past couple years I’ve changed my practice to performing peripheral (i.e. radial) a-lines with full barrier sterile prep (drape, gown, etc.) I think there is enough data – highlighted by this review – to show that there is a significant risk of BSI with arterial lines and support the need to practice placing a-lines under full sterility.

Many argue that a-lines rarely get infected and that there is minimal evidence that full barrier preparation significantly reduces the rate of CRBSI’s- the latter is certainly true. So why should you take the time for a full barrier sterile prep? Interestingly, the authors specific mention that many US intensivists do not believe that a-lines are a significant source of BSI.

But here’s the counterpoint: In the setting of a defined, proven risk – shouldn’t the burden of proof be to show there is no significant risk with less precaution, before doing less?

Here is the question to everyone reading:  The decision to use full vs. partial barrier prep for peripheral a-lines is certainly a highly debatable topic – where do you stand?

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