Central Venous Line Risks Vary by Insertion Site

A new study reveals that the risk of blood infection or thrombosis is lowest when central line catheters are placed in the subclavian or jugular vein.

Researchers at Centre Hospitalier Universitaire de Caen (France), Centre Hospitalier Général (Versailles, France), and other institutions conducted a multicenter trial in which they randomly assigning 3,027 adult intensive care unit (ICU) patients to non-tunneled central venous catheterization of the subclavian, jugular, or femoral vein. In all, 3,471 catheters were placed, of which 2,532 patients qualified for a three choice comparison, and the rest to a two choice comparison. The primary outcome measure was a composite of catheter-related bloodstream infection and symptomatic deep vein thrombosis (DVT).

The results showed that in the three-choice comparison, there were 8, 20, and 22 primary outcome events in the subclavian, jugular, and femoral groups, respectively. In pair-wise comparison, primary outcome risk was significantly higher in the femoral and jugular groups than in the subclavian group, whereas the risk in the femoral group was similar to that in the jugular group. In the three-choice comparison, pneumothorax occurred in association with 1.5% of the subclavian vein insertions, and 0.5% of the jugular vein insertions.

In terms of major mechanical complications, a subgroup analysis showed significant interaction between the use of ultrasonography and the comparison between the femoral group and the jugular group. However, since the overall risk of mechanical, infectious, and thrombotic complications of grade 3 (or higher) was similar among the three insertion sites, the researchers suggest that an ideal site for central venous catheter insertion does not in fact exist. The study was published on September 24, 2015, in the New England Journal of Medicine (NEJM).

“There are probably several factors contributing to our findings. The subcutaneous course of the subclavian catheter before entry into the vein is generally longer than for the other two types,” concluded lead author Jean-Jacques Parienti, MD, PhD, and colleagues. “The subclavian insertion site has the lowest bacterial bioburden and is relatively protected against dressing disruption. Finally, subclavian catheters are associated with less thrombosis.”

Central line catheters are used to administer medication or fluids, obtain blood tests (specifically mixed venous oxygen saturation), and directly obtain cardiovascular measurements such as the central venous pressure (CVP). Other, long-term indications included administration of intravenous antibiotics, parenteral nutrition (especially in chronically ill patients), dialysis, and chemotherapy. Complications include pneumothorax, central-line associated bloodstream infections (CLABSIs), thrombosis, and hemorrhage.

Related Links:
Centre Hospitalier Universitaire de Caen
Centre Hospitalier Général