"Catheter-Related Infections and Thrombosis in ICU Patients". The New England Journal of Medicine. 2015. PubMed
Links to original sources: Wiki Journal Post Full Journal Article
Contents 1 Clinical Question 2 Bottom Line 3 Major Points 4 Guidelines 5 Design 6 Population 6.1 Inclusion Criteria 6.2 Exclusion Criteria 6.3 Baseline Characteristics 7 Interventions 8 Outcomes 8.1 Primary Outcome 8.2 Secondary Outcomes 9 Criticisms 10 Funding 11 Further Reading
Does the choice of insertion site for nontunneled central venous catheterization in ICU patients affect the risk of catheter-related bloodstream infection and symptomatic deep-vein thrombosis?
Subclavian-vein catheterization in ICU patients is associated with a lower risk of catheter-related bloodstream infection and symptomatic thrombosis compared to jugular-vein or femoral-vein catheterization, but carries a higher risk of mechanical complications, primarily pneumothorax.
The choice of insertion site for central venous catheters is critical given differential infection risks and mechanical complication profiles for subclavian, jugular, and femoral veins. This study, known as the 3SITES study, determined that subclavian-vein catheterization offers a lower risk of bloodstream infection and thrombosis but a higher risk of pneumothorax when compared with insertion at other sites in ICU patients.
The CDC (Centers for Disease Control and Prevention) recommends using a subclavian site over a jugular or femoral site in adult patients to minimize infection risk.
- Multicenter, randomized, controlled trial. - N=3,471 catheters in 3,027 adult ICU patients. - Intervention: Nontunneled central venous catheterization at subclavian, jugular, or femoral vein. - Allocation: 1:1:1 ratio when all sites suitable (three-choice scheme), 1:1 ratio when two sites suitable (two-choice scheme). - Setting: Four university-affiliated hospitals and five general hospitals representing 10 ICUs in France. - Enrollment: December 2011 through June 2014. - Follow-up: Until ICU discharge or death.
- Inclusion Criteria: Patients ≥18 years of age admitted to ICU with need for nontunneled central venous catheter accessible via at least two of three veins (subclavian, jugular, femoral). - Exclusion Criteria: Patients without suitable sites for two or more of the designated veins. - Baseline Characteristics: Well balanced between groups.
- Patients were randomly assigned to have a nontunneled central venous catheter inserted into either the subclavian, jugular, or femoral vein.
- Primary Outcome: Incidence of major catheter-related complications, defined as combined risk of catheter-related bloodstream infection and symptomatic deep-vein thrombosis. - Secondary Outcomes: Time to catheter-tip colonization, time to total deep-vein thrombosis, and major mechanical complications (grade 3 or higher).
- Use of ultrasonographic guidance as an insertion aid was not randomized, which could have influenced risk assessments for mechanical and infectious complications. - Chlorhexidine bathing and chlorhexidine-impregnated dressings were not utilized, leaving their potential effect unassessed. - The study did not involve the use of peripherally inserted central venous catheters.
- Supported by a grant from the Hospital Program for Clinical Research, French Ministry of Health. - CareFusion provided chlorhexidine products free of charge.
- For a complete list of 3SITES study investigators and other details, refer to the Supplementary Appendix available at NEJM.org.