OBJECTIVE: To evaluate the role of skin and subcutaneous tissue trauma at the time of catheter implant procedure as a determinant of catheter loss from infectious complications. DESIGN: Nonrandomized study with prospective collection of data. PATIENTS: Consecutive patients were divided into three groups based upon how the catheter was exited through the skin: group 1, procedure involved pulling tubing, with a permanently bonded catheter adapter, through the exit-site wound (n = 43); group 2, same as group 1 except exit wounds were closed around the catheter with a suture (n = 20); group 3, procedure involved pulling only tubing through the exit wound (n = 61). SETTING: Primary medical center for a health maintenance organization. MAIN OUTCOME MEASURES: Log rank comparisons of Kaplan-Meier analyses of first occurrences of infectious events and overall catheter survival. RESULTS: The risk of first exit-site infection (p < 0.001), tunnel infection (p < 0.001), catheter infection-related peritonitis (p < 0.001), and catheter loss (p < 0.01) were greatest in group 1 with large exit wounds, and lowest in group 3 with small exit wounds. CONCLUSIONS: The study demonstrates the importance of careful dissection and exit-site construction. The exit site should consist of the smallest hole possible that permits passage of only the tubing and leaves the skin snug around the catheter. The present report incriminates catheter designs employing permanently bonded adapters that result in large pericannular wounds that are prone to infection and catheter loss.

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