Subclavian-vein catheterization was linked with a lower risk of bloodstream infection and symptomatic thrombosis, but a higher risk of pneumothorax, versus jugular vein or femoral vein catheterization, French researchers reported.
In a comparison of insertion sites among more than 3,000 randomized ICU patients, the risk of blood infection or thrombosis was lowest for subclavian catheters when compared with femoral catheters (HR 3.5, 95% CI 1.5-7.8, P=0.003), or jugular catheters (HR 2.1, 95% CI 1.0-4.3, P=0.04), according to Jean-Jacques Parienti, MD, PhD, of Centre Hospitalier Universitaire de Caen in France, and colleagues.
However, pneumothorax requiring a chest tube were necessary for 1.5% of the subclavian patients, they wrote in the New England Journal of Medicine.
“There are probably several factors contributing to our findings,” they explained. “The subcutaneous course of the subclavian catheter before entry into the vein is generally longer than for the other two types. The subclavian insertion site has the lowestbacterial bioburden and is relatively protected against dressing disruption. Finally, subclavian catheters are associated with less thrombosis.”
As part of the 3SITES multicenter randomized clinical trial, Parienti’s team looked at the risk for developing catheter-related deep vein thrombosis (DVT) or bloodstream infection in 3,027 adult patients in 10 ICUs in France from the end of 2011 through mid-2014.
At least two insertion sites had to be viable for the patient to be included in the study. If only two sites were viable or only the right or left side were suitable, the sites were assigned a 1:1 randomization scheme, but if all three were options, a 1:1:1 randomization scheme was used.
Patients and devices were monitored for bloodstream infectionsand symptomatic and asymptomatic DVT from the time of insertion through 48 hours after removal. For secondary outcome measures, the researchers tracked the mechanical safety of the device.
Overall, 3,471 central lines were placed in 3,027 patients, and 2,532 of those patient qualified for the three-choice comparison. Among those three-choice patients, infection or DVT occurred in eight out of 843 subclavian patients, 20 out of 845 jugular patients, and 22 out of 844 femoral catheterization patients. These rates worked out to 1.5, 3.6, and 4.6 per 1,000 catheter-days, respectively (P=0.02).
Pneumothorax requiring a chest-tube insertion was necessary for 13 (1.5%) of patients in the subclavian group, and four (0.5%) patients in the jugular group.
When the researchers compared the insertion sites to one another in a pairwise analysis, the risk for infection or thrombosis was similar between patients in the femoral group and the jugular group (HR 1.3, 95% CI 0.8-2.1, P=0.30)
The authors noted that the findings were consistent with the CDC guideline for “preventing intravascular catheter-related infections.”
In terms of major mechanical complications, a subgroup analysis showed a significant interaction between the use of ultrasonography and the comparison between the femoral group and the jugular group (P=0.007), the authors reported. In addition, there was a nonsignificant trend for an interaction between the use of ultrasonography and the comparison between the femoral group and the subclavian group (P=0.07), they stated.
However, the authors suggested that the overall risk of mechanical, infectious, and thrombotic complications of grade 3 or higher was similar among the three insertion sites, which suggests that an ideal site for central venous catheter insertion does not exist when all types of complications are considered to be of equal concern.
Study limitations included missing data for the mechanical complications on more than half of the catheters, and the lack of randomization for the use of ultrasound during insertion.
The authors also noted that daily chlorhexidine bathing and chlorhexidine-impregnated dressings were not used.
“Whether these measures influence the difference in infectious risk between insertion sites is unknown,” they acknowledged.
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