"Catheter-Related Infections and Thrombosis in ICU Patients". The New England Journal of Medicine. 2015. PubMed • Full text • PDF

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

Clinical Question

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?

Bottom Line

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.

Major Points

Guidelines

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.

Design

- 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.

Population

- 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.

Interventions

- Patients were randomly assigned to have a nontunneled central venous catheter inserted into either the subclavian, jugular, or femoral vein.

Outcomes

- 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).

Criticisms

- 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.

Funding

- Supported by a grant from the Hospital Program for Clinical Research, French Ministry of Health.
- CareFusion provided chlorhexidine products free of charge.

Further Reading