Clinical question: Which insertion site for central venous catheterization results in fewer complications?
Bottom line: Central venous catheterization via a subclavian insertion site, as compared with femoral and jugular sites, decreases the risk of bloodstream infections and symptomatic deep vein thromboses (DVTs), but results in more pneumothoraces. This risk could potentially be mitigated with the use of ultrasound guidance during catheter insertion. ((LOE = 1b)
Reference: Parienti JJ, Mongardon N, Mégarbane B, et al. Intravascular complications of central venous catheterization by insertion site. N Engl J Med 2015;373(13):1220-1229.
Study design: Randomized controlled trial (nonblinded)
Funding source: Government
Allocation: Concealed
Setting: Inpatient (ICU only)
Synopsis
These investigators randomized 3027 patients in the intensive care unit who required nontunneled central venous access to receive 3471 intravenous catheters at one of three insertion sites: subclavian, jugular, or femoral. The catheters were placed by residents or staff physicians who had prior experience in the procedure. All patients had peripheral blood cultures and catheter tip cultures sent at the time of catheter removal. Patients also underwent compression ultrasonography at the insertion site within two days of catheter removal to assess for DVT. The three groups were well-balanced at baseline and the median duration of catheter use was five days. Analysis was by intention to treat.
The primary composite endpoint of catheter-related bloodstream infections and symptomatic DVTs occurred less frequently in the subclavian group than in the other two groups (1.5 events per 1000 catheter-days in the subclavian group, 3.6 in the jugular group, 4.6 in the femoral group). The risk of this outcome was greater in both the femoral and jugular groups when compared directly with the subclavian group (femoral vs subclavian: hazard ratio [HR] = 3.5; 95% CI 1.5-7.8; P = .003; femoral vs jugular: HR = 2.1; 1.0-4.3; P = .04). The subclavian group, however, did have the highest risk of mechanical complications, mainly pneumothoraces.
When all three bad outcomes (infections, DVTs, mechanical complications) are pooled together, the differences between the three groups are not as compelling (percentage of catheters with overall complications: 3.1% subclavian, 3.7% jugular, 3.4% femoral).
Dr. Kulkarni is an assistant professor of hospital medicine at Northwestern University in Chicago.
