Intravascular Complications of Central Venous Catheterization by Insertion Site
Authors: Parienti JJ, Mongardon N, Mégarbane B, et al
N Engl J Med. 2015;373:1220-1229
The optimal location for central venous catheter (CVC) placement remains a contentious debate, despite years of use and thousands of published reports. This study was designed to randomly assign adult intensive care unit (ICU) patients in France to undergo CVC insertion at one of the three most common CVC sites: the internal jugular (IJ), subclavian (SC), or femoral (F) vein.
The primary outcome was a combination of central line-associated bloodstream infections (CLABSI) and symptomatic deep venous thrombosis (DVT). For the period of study, 3471 catheters were inserted in 3027 patients.
The risk for the primary outcome was similar in the F and IJ groups (hazard ratio [HR], 1.3; P = 0.30) and significantly higher in the F and IJ groups compared with the SC group (HR, 3.5 and 2.1, respectively). Pneumothorax requiring a chest tube was associated with 1.5% of SC vein insertions and 0.5% of IJ vein insertions. Overall, SC vein catheterization was associated with a lower risk for CLABSI and symptomatic DVT and a higher risk for pneumothorax than IJ or F vein catheterization.
CVC use is associated with infectious, thrombotic, and mechanical complications that vary by insertion site. Such complications as CLABSI have a significant effect on morbidity, mortality, and healthcare costs.[1-4] The results of this study are not surprising to most ICU practitioners, but they comprise the strongest evidence to date to guide CVC insertion location practices.
In particular, the SC insertion site had the lowest risk for combined infectious/thrombotic outcomes, but was also associated with the highest rates of mechanical insertion complications (pneumothorax requiring intervention). These findings are consistent with the Centers for Disease Control and Prevention (CDC) guidelines for preventing CLABSI, in which the recommendation is to “use a subclavian site, rather than a jugular or a femoral site, in adult patients.”
Looking at the individual outcomes, SC insertions were associated by far with the highest rates of mechanical complications, whereas F insertions had the highest rates of thrombotic complications and IJ insertions had the highest rates of infectious complications. From a practical perspective, the results of this study support adherence to the CDC guidelines, with potential individualization for patients at particular risk for either mechanical or thrombotic complications, in whom a particular site may be given preference.