Author: Lauran Wirfs
Central venous access is an important procedure for critically ill patients. One consideration when placing a venous catheter is the risk of catheter-related bloodstream infections (CRBIs), which can be a significant cause of morbidity and mortality in hospitalized patients. In 2012, there were 15 million central venous catheter (CVC) days per year in the US in ICUs, and the rate of infections per catheter days is 3/1000. This post looks at a systematic review done by Marik et. al. that examines CRBIs among internal jugular, subclavian, and femoral central venous sites.
Is there a statistical difference among CRBI rates when comparing femoral vs internal jugular vs subclavian central venous placement?
The authors performed a literature review of various database including: MEDLINE, Embase, Cochrane Register of Controlled Trials, citation reviews of relevant primary and review articles, and Google to search for randomized controlled trials and cohort studies examining rates of CRBIs at various central venous sites. Based on their preselected criteria, they found 8 cohort studies and 2 randomized controlled trials dating from 1998-2010.
The two RCTs followed 1,006 catheters for a mean of 8.3 ± 2.5 days/catheter and the eight cohort studies followed 16,370 catheters for mean of 6.4 ± 1.8 days/catheter. The total percentage of catheters at each site were femoral at 18.4%, internal jugular at 63%, and subclavian at 18.6%.
Two cohort studies (Nagashima et. al. and Lorente et. al.) were considered outliers based on the finding that their treatment effect was larger than expected by chance alone. When they were removed from the systematic review, the data showed no statistical difference between the sites when comparing femoral vs internal jugular sites or femoral vs subclavian sites.
In the data, earlier studies did prefer placement in the subclavian and the internal jugular over the femoral, and subsequently showed a higher infection rate at the femoral sites. Later studies have a lower overall infection rate likely secondary to our improved use of sterile technique (e.g. use of chlorhexidine, sterile gloves, hand-hygiene, antimicrobial-coated catheters, etc). Go us! In fact, the study stated that in 1998 the rate of CRBIs in the United States was 5.32/1,000 catheter days, and that by 2012, it had been reduced to 2.05/1,000 catheter days.
Of note, currently the CDC has a 1A recommendation to avoid using the femoral site when possible due to risk of CRBIs. It is based on the two RCT studies included in this systematic review. However, based on this review, it is likely more advantageous to choose the site based on your level of comfort and other mitigating circumstances as there was no statistical difference in CRBIs among these three sites.
Go where you please!
To quote the great Dr. Seuss:
“You have brains in your head
You have feet on your shoes
You can steer yourself
Any direction you choose
You’re on your own. And you know what you know
And YOU are the guy who’ll decide where to go!”
…Of course, unless it is contraindicated, like don’t place a central line in the subclavian for a dialysis patient…
Marik, P., MD, Flemmer, M., MD, & Harrison, W., PhD. (2012). The risk of catheter-related bloodstream infection with femoral venous catheters as compared to subclavian and internal jugular venous catheters: A systematic review of the literature and meta-analysis. Critical Care Medicine, 40(8)