On the Shoulders of Giants
Better than we thought
This systematic review of RCTs and cohort studies found there was no difference in bloodstream infections with the femoral vs. subclavian (SC) sites and no difference between internal jugular (IJ) and femoral lines when 2 statistical outlier studies were removed from the analysis. It also found most of the increased risk of femoral line infections was in earlier studies, and the differences were negligible between femoral, SC, and IJ in more recent research. Recent research also confirms this up to 5 days. Although the recent 3SITES RCT in 2015 found SC had the lowest risk of infection and clot but the highest risk of pneumothorax; IJ and femoral had statistically equal rates of infection.
Femoral lines are as safe as IJ lines and almost as safe as SC lines, when placed with meticulous sterile technique. EMCrit has a great post on this and interview with the primary author, Dr. Marik. I found the additional references linked above thanks to Scott Weingart.
Crit Care Med. 2012 Aug;40(8):2479-85. doi: 10.1097/CCM.0b013e318255d9bc.
The risk of catheter-related bloodstream infection with femoral venous catheters as compared to subclavian and internal jugular venous catheters: a systematic review of the literature and meta-analysis.
1Eastern Virginia Medical School, Norfolk, VA, USA. firstname.lastname@example.org
- Central venous catheters: follow the evidence, not the guidelines. [Crit Care Med. 2012]
- ACP Journal Club. Review: femoral and subclavian or internal jugular venous catheters do not differ for bloodstream infections. [Ann Intern Med. 2012]
- The authors reply. [Crit Care Med. 2013]
- Not all catheter-days are equal. [Crit Care Med. 2013]
- The author replies. [Crit Care Med. 2013]
- Central venous catheter site: should we really stop avoiding the femoral vein? [Crit Care Med. 2013]
- The author replies. [Crit Care Med. 2013]
- The risk of catheter-related bloodstream infection in different catheter insertion sites: evidence versus guidelines. [Crit Care Med. 2013]
Catheter-related bloodstream infections are an important cause of morbidity and mortality in hospitalized patients. Current guidelines recommend that femoral venous access should be avoided to reduce this complication (1A recommendation). However, the risk of catheter-related bloodstream infections from femoral as compared to subclavian and internal jugular venous catheterization has not been systematically reviewed.
A systematic review of the literature to determine the risk of catheter-related bloodstream infections related to nontunneled central venous catheters inserted at the femoral site as compared to subclavian and internal jugular placement.
MEDLINE, Embase, Cochrane Register of Controlled Trials, citation review of relevant primary and review articles, and an Internet search (Google).
Randomized controlled trials and cohort studies that reported the frequency of catheter-related bloodstream infections (infections per 1,000 catheter days) in patients with nontunneled central venous catheters placed in the femoral site as compared to subclavian or internal jugular placement.
Data were abstracted on study design, study size, study setting, patient population, number of catheters at each insertion site, number of catheter-related bloodstream infections, and the prevalence of deep venous thrombosis. Studies were subgrouped according to study design (cohort and randomized controlled trials). Meta-analytic techniques were used to summarize the data.
Two randomized controlled trials (1006 catheters) and 8 cohort (16,370 catheters) studies met the inclusion criteria for this systematic review. Three thousand two hundred thirty catheters were placed in the subclavian vein, 10,958 in the internal jugular and 3,188 in the femoral vein for a total of 113,652 catheter days. The average catheter-related bloodstream infections density was 2.5 per 1,000 catheter days (range 0.6-7.2). There was no significant difference in the risk of catheter-related bloodstream infections between the femoral and subclavian/internal jugular sites in the two randomized controlled trials (i.e., no level 1A evidence). There was no significant difference in the risk of catheter-related bloodstream infections between the femoral and subclavian sites. The internal jugular site was associated with a significantly lower risk of catheter-related bloodstream infections compared to the femoral site (risk ratio 1.90; 95% confidence interval 1.21-2.97, p=.005, I²=35%). This difference was explained by two of the studies that were statistical outliers. When these two studies were removed from the analysis there was no significant difference in the risk of catheter-related bloodstream infections between the femoral and internal jugular sites (risk ratio 1.35; 95% confidence interval 0.84-2.19, p=0.2, I=0%). Meta-regression demonstrated a significant interaction between the risk of infection and the year of publication (p=.01), with the femoral site demonstrating a higher risk of infection in the earlier studies. There was no significant difference in the risk of catheter-related bloodstream infection between the subclavian and internal jugular sites. The risk of deep venous thrombosis was assessed in the two randomized controlled trials. A meta-analysis of this data demonstrates that there was no difference in the risk of deep venous thrombosis when the femoral site was compared to the subclavian and internal jugular sites combined. There was, however, significant heterogeneity between studies.
Although earlier studies showed a lower risk of catheter-related bloodstream infections when the internal jugular was compared to the femoral site, recent studies show no difference in the rate of catheter-related bloodstream infections between the three sites.
PMID: 22809915 [PubMed - indexed for MEDLINE]