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Update in Hospital Medicine
- Bradley E. Flansbaum, DO, MPH; and
- Jeanne M. Huddleston, MD
- From Columbia Presbyterian Medical Center; New York, NY 10032; and Mayo Clinic; Rochester, MN 55905.
The Editors welcome submissions for possible publication in the Letters section. Authors of letters should:
•Include no more than 300 words of text, three authors, and five references
•Type with double-spacing
•Send three copies of the letter, an authors' form signed by all authors, and a cover letter describing any conflicts of interest related to the contents of the letter.
Letters commenting on an Annals article will be considered if they are received within 6 weeks of the time the article was published. Only some of the letters received can be published. Published letters are edited and may be shortened; tables and figures are included only selectively. Authors will be notified that the letter has been received. If the letter is selected for publication, the author will be notified about 3 weeks before the publication date. Unpublished letters cannot be returned.
Annals welcomes electronically submitted letters.
IN RESPONSE:
Reducing problems related to central venous catheter placement is a high priority, and we agree with Dr. Painton that appropriate patient screening is prudent and may help avoid needless line-related complications. Typically, patients with significant comorbid conditions who are seen in the intensive care unit have longer hospital stays, in addition to continued needs for intravenous access. The patients in the study by Merrer and colleagues (1) reflect this and, as a result, required longer placement of both subclavian and femoral lines. The investigators stated that “catheters were removed at the discretion of the ICU [intensive care unit] team when they were no longer needed or if an adverse event occurred.” Whether greater reductions in catheter duration were possible is unclear.
In critically ill patients without peripheral access in whom brief needs for central line placement can be predicted (probably a limited subset), a strategy favoring anatomic sites with lower complication rates would be appropriate. While infectious and thrombotic complications are always a risk, it is unlikely that these problems “all occur after 72 hours,” and good judgment should direct the location of any intravascular device. If avoiding pneumothorax is the sole concern, subclavian access should be attempted at the discretion of the physician. Ultrasound guidance also reduces the potential for complications (2).
In patients with diabetic ketoacidosis, such as those Dr. Painton describes, large-bore peripheral lines should be the optimal choice for access. They will both minimize complications and maximize fluid resuscitation rates if the patients are very ill.
Bradley E. Flansbaum, DO, MPH
Columbia Presbyterian Medical Center; New York, NY 10032
The Editors welcome submissions for possible publication in the Letters section. Authors of letters should:
•Include no more than 300 words of text, three authors, and five references
•Type with double-spacing
•Send three copies of the letter, an authors' form signed by all authors, and a cover letter describing any conflicts of interest related to the contents of the letter.
Letters commenting on an Annals article will be considered if they are received within 6 weeks of the time the article was published. Only some of the letters received can be published. Published letters are edited and may be shortened; tables and figures are included only selectively. Authors will be notified that the letter has been received. If the letter is selected for publication, the author will be notified about 3 weeks before the publication date. Unpublished letters cannot be returned.
Annals welcomes electronically submitted letters.
- Copyright ©2004 by the American College of Physicians
