1. In the three-choice comparison of different catheter insertion sites, the femoral group had a higher incidence of major catheter-related complications compared to the jugular and subclavian catheter insertion site.
2. The frequency of mechanical complications differed based on insertion-site.
Evidence Rating Level: 1 (Excellent)
Study Rundown: Infectious, thrombotic, and mechanical complications have been associated with central venous catherization of the subclavian, jugular and femoral veins. These complications effect the morbidity, mortality and health care costs of catheter-related blood stream infections. The 3SITES study evaluated the risks of catheter-related bloodstream infection or symptomatic catheter-related deep-vein thrombosis (DVT) for ICU patients. In this randomized, controlled trial, catheterization of the subclavian vein was associated with a significantly reduced risk of the combined outcome of catheter-related bloodstream infection and symptomatic DVT. Subclavian-vein catheterization was associated with a significantly higher risk of mechanical complications such as pneumothorax. In this study the incidence of total DVT should be interpreted with caution due to missing data on 59% of asymptomatic DVT patients.
In-Depth [randomized controlled trial]: A total of 3027 patients and 3471 catheters were included in the 3SITES study which was a multicenter randomized, controlled trial. Patients were evaluated for all three venous access sites (subclavian, jugular, and femoral). If all catheter insertion sites were suitable for placement the insertion site was assigned in a 1:1:1 randomization. If only two sites were suitable a 1:1 randomization was implemented. The primary outcome was incidence of major catheter-related complications from the time of catheter insertion to 48 hours after catheter removal. Secondary outcomes included the time to catheter-tip colonization and time to total DVT after catheter removal.
There were a total of 50 nonduplicate primary outcomes with 8,20, and 22 primary outcome events occurring in the subclavian, jugular, and femoral groups, respectively. A three-choice comparison of these events showed 1.5, 3.6, and 4.6 events per 1000 catheter-days, respectively (p=0.02). The femoral group had a significantly higher risk of primary outcome compared to the subclavian group (HR = 3.5; 95% [CI], 1.5-7.8; p = 0.003). Furthermore, the jugular group had a significantly higher risk of primary outcomes compared to the subclavian group (HR =2.1; 95% [CI], 1.0-4.3; p=0.04). The risk in the femoral group was similar to that in the jugular group (p=0.3). Major mechanical complications, primarily pneumothorax which required chest-tube insertion, occurred in 1.5% of the subclavian-vein insertions and 0.5% of the jugular-vein insertions.
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