Is IJ or Subclavian Safer Under Ultrasound Guidance?

Written by Alex Chen

Spoon Feed
In this randomized trial of anesthetized patients, there was no difference in the rate of pneumothorax and arterial puncture between ultrasound-guided internal jugular venous (IJ) catheters and ultrasound-guided subclavian venous (SCV) catheterization. However, SCV access took longer and had a higher rate of catheter misplacement.

Why does this matter?
Many an ICU rounds are filled with the never ending debate between which line is the best. This study unfortunately can’t directly answer that question, but it attempts to wrangle the last (and greatest) blind central line from my cold dead hands.

Well the ultrasound is taken, I guess I’ll do a subclavian!
This was a randomized study performed in three South Korean medical centers. 1,350 patients were placed under general anesthesia prior to initiation of the line. Both IJ and SCV lines were placed by experienced anesthesiologists (go figure) under ultrasound guidance. The IJ approach had lower arterial puncture rate (0.1% vs 0.6%) and pneumothorax rate (0% vs 0.1%). Combining these two endpoints, the total complication rate was not statistically different (p = 0.248). However, SCV access had a higher rate of catheter misplacement (5.9% vs 0.4%, usually due to SCV line terminating in the IJ) and access time (15s vs 5s) compared to the IJ approach. Due to a lower than expected complication rate, this study was not powered to determine superiority. This amazingly low rate of complications for central venous catheterization is in part attributable to the median patient BMI of 23 kg/cm2. I doubt that this study applies to American EDs where we do central lines more frequently on patients who are awake and often obese. Nonetheless, given this study’s low complication rate for SCV lines combined with the low risk of infection, I guess it’s time to practice the US-guided SCV line. Ugh.

Source
Complications in internal jugular vs subclavian ultrasound-guided central venous catheterization: a comparative randomized trial. Intensive Care Med. 2019 Jul;45(7):968-976. doi: 10.1007/s00134-019-05651-9. Epub 2019 May 29.

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Reviewed by Thomas Davis

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