Major complications related to insertion of central line catheters remain: infection, thrombosis, and “mechanical complications”(read: pneumothorax, arterial puncture). And, central lines have three typical locations: subclavian, jugular, and femoral.
Wouldn’t it be cute if each of these catheter insertion sites each had their own specific realm of superiority?
And, based on this randomized trial of 3,471 catheter insertion events, they just about do:
- The femoral site has the fewest mechanical complications, but the most thrombosis (1.4%).
- The subclavian site had the fewest infections (0.5%) and thrombotic events (0.5%), but the most mechanical complications (2.1%).
- And the jugular site was essentially a middle ground between the two, although, had the greatest infection rate (1.4%).
However, many of these differences need be taken with a grain of salt. Ultrasound was not mandated, which probably led to the unusual incidence of mechanical complications for the jugular approach. Specific antimicrobial dressings were not used regularly. There was a high rate of failure and crossover in the subclavian arm (14.7%). Then, the number of complications for each were measured typically in the near-single digits, while 469 patients died before catheter removal – a large enough number of potentially unmeasured events to significantly affect the primary outcome. Only symptomatic patients were screened for thrombosis – again, leaving many patients with potentially missed outcomes.
So, in the end, what’s likely best? A skilled subclavian – or one guided by an ultrasound approach – is probably ideal, but should be avoided if clinician comfort is low. Following that, an ultrasound-guided jugular approach is likely best. It is not reasonable to suggest the femoral site would routinely be superior to either approach, but these very low rates of complications indicate it need not be shunned when clinically appropriate.
“Intravascular Complications of Central Venous Catheterization by Insertion Site”