EBQ:3SITES Trial

Complete Journal Club Article

Parienti JJ, et al. "Intravascular Complications of Central Venous Catheterization by Insertion Site". NEJM. 2015. 373(13):1220-1229.
PubMed Full text PDF

Clinical Question

Do major complications of central venous catheters differ by site of insertion (central, subclavian and femoral)?

Conclusion

The subclavian site, when compared to the IJ or femoral site, is associated with fewer bloodstream infections and DVTs. The rate of mechanical complications is greatest

Major Points

Central venous catheters(CVCs) are often required to establish venous access in critically ill patients in order to administer rapid fluid resuscitation, blood products, and vasopressors. The sites of insertion fall into three locations: Internal jugular (IJ), subclavian, and femoral. The major complications of concern include: catheter-related bloodstream infections (CRBI), DVT, and mechanical complications (e.g. pneumothorax and arterial puncture).

The 3SITES Trial study, a multicenter randomized trial, investigated the complications of the three anatomic sites for CVC insertion in relation to blood stream infections or DVTs. Although subclavian lines appear to have a lower infection rate, there is greater incidence of mechanical complications.

Study Design

• Multicenter (10 ICUs from 4 university and 5 community hospitals in France) randomized, controlled trial
• N=3,471 ICU patients
  • Subclavian (n=1,016)
  • Jugular (n=1,284)
  • Femoral (n=1,171)
• Dates: December 2011 to June 2014
• Analysis: Intention-to-treat
• Primary outcome: Major catheter-related complications (bloodstream infection or symptomatic DVT)
• Secondary: Major mechanical complications
• Median follow up: 5 days

Population

Patient Demographics

• Age 63, 63% male, BMI 26
• Illness severity: SAPS II 57.1
• Co-morbidities:
  • Diabetes 20.5%
  • Cancer 9.0%
  • AIDS 1.4%
• Complicating Conditions (IJ group)
  • Neutropenia (<500/mm³ 1.8%
  • Tracheotomy 1.7%
  • Antibiotic therapy 54.1%
  • Anticoagulation 30.4%
  • Parenteral nutrition 5.8%

Inclusion Criteria

• 18 years or older
• Admitted to the ICU and required central venous access
• Had at least 2/3 acceptable insertion sites (femoral, jugular, or subclavian)

Exclusion Criteria

• Only one access site available

Interventions

• Randomization (1:1:1) to one of the three anatomic sites(subclavian, jugular, or femoral CVC)
• Randomization stratified according to ICU and according to the use of antibiotics versus no therapy
• All ICUs used the French Haute Autorite de Sante checklist and US guidelines for preventing catheter-related infections
• Placement followed standard Seldinger technique with the use of anatomical landmarks or ultrasound guidance
• Catheter-related bloodstream infection was defined by catheter-tip colonized with the same phenotypic microorganism isolated from peripheral blood cultures
• Two days after CVCremoval ultrasound was used to detect asymptomatic or confirm symptomatic catheter-related DVT
• Sterile preparations used:
  • Alcoholic chlorhexidine 43.1%
  • Alcoholic povidone-iodine 43.1%
  • Aqueous povidone-iodine 9.8%
• Procedural Guidance:
  • Use of anatomical landmarks 32.7% (femoral 74%, subclavian 86%), insertion time 12.6 min, insertion failure 7.7% (subclavian 14.7%)
  • Duration of catheterization 6.5 days

Outcomes

Primary Outcomes

Catheter-related bloodstream infection or symptomatic DVT

Femoral vs subclavian: 25 vs. 8 (HR 3.5; 95% CI 1.5-7.8; P=0.003)

Jugular vs subclavian: 23 vs. 11 (HR 2.1; 95% CI 1.0-4.3; P=0.04)

Femoral vs jugular: 33 vs. 30 (HR 1.3; 95% CI 0.8-2.1; P=0.30)

Secondary Outcomes

Bloodstream infection

Femoral vs subclavian: 11 vs. 4 (HR 3.4; 95% CI 1.5-7.8; P=0.048)

Jugular vs subclavian: 13 vs. 6 (HR 2.3; 95% CI 0.8-6.2; P=0.11)

Femoral vs jugular: 15 vs. 21 (HR 0.9; 95% CI 0.5-1.8; P=0.81)

Symptomatic DVT

Femoral vs subclavian: 15 vs. 5 (HR 3.4; 95% CI 1.5-7.8; P=0.02)

Jugular vs subclavian: 10 vs. 6 (HR 1.8; 95% CI 0.6-4.9; P=0.29)

Femoral vs jugular: 20 vs. 9 (HR 2.4; 95% CI 1.1-5.4; P=0.04)

Criticisms & Further Discussion

• This study confirms what was demonstrated in another single site study where subclavian catheters had lower infection rates.
• High risk patients may have been excluded from the subclavian site.
• Crash line complications and infections cannot be extrapolated from this data
• Mechanical complications were a secondary outcome and reduction in infections may not be outweighted by the risk of mechanical complications in some settings.
• The the study was ICU based and "crash lines" in the ER cannot be abstracted from this population.
• Ultrasound guidance was not randomized and use may affect results positively or negatively.

External Links

RebelEM Podcast - Vascular Access

See Also

• Central venous catheterization

Funding

• Grant from the Hospital Program for Clinical Research, French Ministry of Health

References

Authors

Daniel Ostermayer