Fewer Complications With Subclavian Catheterization

Tara Haelle

September 24, 2015

Central venous catheterization of the subclavian vein was associated with the lowest risk for bloodstream infections and symptomatic thrombosis compared with insertions at the jugular or femoral veins, according to a randomized controlled trial published in the September 24 issue of the New England Journal of Medicine.

"These findings are consistent with the Centers for Disease Control and Prevention guideline for preventing intravascular catheter-related infections, in which the recommendation is to 'use a subclavian site, rather than a jugular or a femoral site, in adult patients,' " report Jean-Jacques Parienti, MD, PhD, from the Department of Biostatistics and Clinical Research at Centre Hospitalier Universitaire, Caen, France, and colleagues.

However, subclavian vein catheters carry a greater risk for pneumothorax, the authors found. Because pneumothorax can be promptly diagnosed and treated, which is less certain for catheter-related bloodstream infection or deep-vein thrombosis, "decisions regarding the choice of insertion site should therefore be considered on a case-by-case basis," they write.

The study confirms the findings of prior smaller studies and showed an overall low complication rate, with approximately 97% of catheters in each group inserted safely, noted Eli Perencevich, MD, an infectious disease epidemiologist at the University of Iowa, Iowa City.

"When all complications are included, it doesn't appear there is a preferred site for catheter insertion," Dr Perencevich told Medscape Medical News. "However, since hospitals are penalized for infections, and not other complications, there may be a preference for choosing the subclavian site, since it is associated with fewer infections."

In the study, the researchers randomly assigned 3471 central venous catheters to be inserted at the subclavian, jugular, or femoral veins in a population of 3027 patients. The researchers used both 1:1:1 and 1:1 randomization ratios, depending on whether two or three insertion sites were appropriate for each participant.

Among patients randomized in the three-choice protocol, eight combined catheter-related bloodstream infections or symptomatic deep-vein thrombosis events occurred among patients with subclavian ports compared with 20 such events among patients with jugular vein catheters and 22 events among patients with femoral vein catheters. Per 1000 catheter-days, these combined complications occurred at a rate of 1.5 events for subclavian vein catheters, 3.6 for jugular vein catheters, and 4.6 for femoral vein catheters (P = .02). Yet 13 of the subclavian-vein insertions (1.5%) were associated with pneumothorax requiring chest tube insertion compared with 4 (0.5%) of insertions at the jugular vein.

Among patients randomly assigned to one of two sites, the risk for complications was no greater for femoral than for jugular vein insertions (hazard ratio [HR], 1.3; 95% confidence interval [CI], 0.8 - 2.1; P = .30). Both subclavian groups in the 1:1 randomizations, however, had lower risk for complications than the femoral (HR, 3.5; 95% CI, 1.5 - 7.8; P = .003) or jugular (HR, 2.1; 95% CI, 1.0 - 4.3; P = .04) groups.

"[T]he expected duration of catheterization is important, because the cumulative risk of infectious and thrombotic complications increases with increasing catheter exposure, whereas the risk of mechanical complications does not," the authors write, a point Dr Perencevich highlighted as well.

"If the doctor expects the catheter to remain in for a short period of time, she might chose a femoral or jugular vein approach to limit the pneumothorax risk, with very little infection or clotting risk since the catheter will be removed before the complication can occur," Dr Perencevich said. "However, if the catheter is to remain in place for many days, it is probably worth the higher risk of pneumothorax associated with the subclavian site, which only occurs when the catheter is inserted, in order to reduce the long-term infection and blood clot risks."

Three explanations may account for the findings, the authors suggest, including a longer subcutaneous course of the subclavian catheter before entry into the vein compared with femoral and jugular catheters. "The subclavian insertion site has the lowest bacterial bioburden and is relatively protected against dressing disruption," they add. "Finally, subclavian catheters are associated with less thrombosis."

One limitation the authors note is that "the incidence of total deep-vein thrombosis should be interpreted with caution, because more than half of the inserted catheters had missing data for this secondary outcome, entirely because of missing data for asymptomatic patients."

In addition, Dr Perencevich noted, the study sites did not use daily chlorhexidine bathing and did not place chlorhexidine dressings at the catheter insertion site.

"Both of these interventions have been shown to reduce catheter-related bloodstream infections," Dr Perencevich said. "Thus, these results might not be generalizable to hospitals that use chlorhexidine bathing and/or chlorhexidine dressings. It is possible that either of these interventions or both could mitigate the infection risk rendering femoral or jugular vein approaches more safe."

The research was funded by the Hospital Program for Clinical Research and the French Ministry of Health. CareFusion provided Chloraprep for the study at no cost. Several coauthors reported receiving personal fees or other support from one or more of the following companies: Astellas Pharma, AstraZeneca, Bio-Rad, bioMérieux, Mérial, Merck Sharp and Dohme, Pfizer, Sanofi, LK2, Covidien, Lilly Oncology, Marvao Medical, CareFusion, Bard, 3M, Fresenius,, LFB, and ASAI. Dr Parienti reports previous grant support and personal fees from ViiV Healthcare, Bristol-Myers Squibb and CareFusion, and personal fees from Gilead Science, Merck Sharp & Dohme, and Janssen Pharmaceuticals.

N Engl J Med. 2015;13:1220-1229. Abstract

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