Background

Three anatomical sites are commonly used to insert central venous catheters, but insertion at each site has the potential for complications including infection, thrombosis and mechanical dysfunction (pneumothorax, hematoma). The authors’ previous research led them to believe that these complications will differ according to the site of insertion.

Clinical Question

Do major complications of central venous catheters differ by site of insertion (central, subclavian and femoral).

Population

Patients age 18 and older who were admitted to an ICU setting and requiring non tunneled central venous vascular access and had at least two of the three sites appropriate for cannulation .Study was conducted in France in a total of ten different ICUs- four university affiliated hospitals and five general hospitals.

Intervention

Patients were randomly assigned 1:1:1 to receive a subclavian, internal jugular or femoral line

Outcomes

Outcome (Primary): Incidence of major catheter-related complications (catheter related blood stream infections and symptomatic deep vein thrombosis- whichever came first) from the time of catheter insertion to 48 hours after catheter removal
Outcome (Secondary):Time to catheter-tip colonization and time to total deep-vein thrombosis after catheter removal. Rate of major mechanical complications during insertion of the central venous catheter and follow-up (arterial injury, hematoma, pneumothorax or other)

Design

Multi-center randomized comparative adverse outcomes trial

Excluded

If only one catheter site was available

Primary Results

Critical Findings

  • The femoral site had the fewest mechanical complications, but the most thrombosis (1.4%)
  • The subclavian site had the fewest infections (0.5%) and thrombotic events (0.5%), but the most mechanical complications (2.1%)
  • The jugular site was essentially a middle ground between the two, although, had the greatest infection rate (1.4%)

Primary Results

  • A total of 3471 catheters were inserted in 3027 patients.
  • There were catheter related complications (blood stream infections and symptomatic deep vein thrombosis) in 8 of the subclavian, 20 of the jugular and 22 of the femoral groups respectively (1.5, 3.6, and 4.6 per 1000 catheter-days; P=0.02) in the three-choice comparison.
  • In a pairwise comparison:
    • Risk of catheter related complications were significantly higher in the femoral group than in the subclavian group (hazard ratio, 3.5; 95% confidence interval [CI], 1.5 to 7.8; P=0.003)
    • Risk of catheter related complications were significantly higher in the jugular group than the subclavian group (hazard ratio, 2.1; 95% CI, 1.0 to 4.3; P=0.04)
    • Risk of catheter related complications was similar in the femoral and the jugular groups  (hazard ratio, 1.3; 95% CI, 0.8 to 2.1; P=0.30).
  • In the three-choice comparison: pneumothorax requiring chest-tube insertion occurred in association with 13 (1.5%) of the subclavian vein insertions and 4 (0.5%) of the jugular-vein insertions.

Strengths

  • Large, multicenter trial
  • Study asked a clear clinical question that was patient centered
  • Only one exclusion criteria increasing applicability

Limitations

  • Selection bias: There was not 1:1:1 randomization for all patients- if the clinician elected to they could choose to opt out of one site and enter to into the 1:1 randomization. This issue could have decreased the complication rate in the subclavian group which was the most commonly excluded site.

  • Ultrasound was not mandated which may have contributed to the high rates of mechanical complications in IJ lines

  • No specific antibiotic dressings used regularly

  • There was a high rate of failure and crossover in the subclavian arm (14.7%)

  • The number of complications for each site were measured in the near-single digits, while 469 patients died before catheter removal – a large enough number of potentially unmeasured events to significantly affect the primary outcome.  

  • Only symptomatic patients were screened for thrombosis – again, leaving many patients with potentially missed outcomes.

Author's Conclusions

“Subclavian-vein catheterization was associated with a lower risk of bloodstream infection and symptomatic thrombosis and a higher risk of pneumothorax than jugular-vein or femoral-vein catheterization.”

Our Conclusions

A skilled or ultrasound guided subclavian is an ideal option but should be avoided if the operator is uncomfortable with he procedure. Based on the low rates of complications (including infectious complications) a femoral line is an excellent option when clinically indicated.

Potential Impact To Current Practice

A subclavian central line should be considered first line in patients in whom infection of the line is the major concern but either an IJ or femoral line may be used if the patient is not a good candidate for a subclavian.

Bottom Line

Although Subclavian lines appear to have a lower infection rate there is the tradeoff of more mechanical complications; ultimately the clinician should decide which site is the most appropriate on a patient to patient basis.

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