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Ruesch, 2002
Merrer, 2001
Deshpande, 2005
Richet, 1990
McKinley, 1999
Goetz, 1998
Morro, 1994

 

EBM reviews CVCrBSI summary

Effects of different insertion sites on the rate of Central Venous Catheter Related Blood Stream Infection.

 

Author: Dr Chris Cairns on behalf of the SICS EBM group 

Author address: Consultant, Intensive Care, Stirling Royal Infirmary, Livilands, Stirling, FK8 2AU.

Correspondence: Chris.Cairns@fvah.scot.nhs.uk

Citation: EBM Reviews. Scottish Intensive Care Society EBM Group. CJS Cairns. Effects of different insertion sites on the rate of Central Venous Catheter Related Blood Stream Infection. 2005.

Background: CVCrBSI is a major and costly cause of mortality and morbidity in critically ill patients. Various strategies and interventions have been suggested to reduce these infections to a minimum. One suggestion has been to avoid some anatomical sites, as there are thought to be associated with higher infection rates.

Objectives: To determine whether there is any relationship between site of insertion of CVCs and the rate of CVCrBSI. 

Search strategy: Medline. (1) central, (2) catheter, (3) catheterization, (4) 2 or 3, (5) 1 and 5, (6) venous, (7) 6 and 7. Resulted in 47 publications. Additional hand searches of reference lists from these publications and review articles.

Selection criteria: Meta-analysis, RCTs or cohort studies comparing rates of catheter colonization or CVCrBSI between different insertion sites. To be included catheter colonization had to be confirmed by semi-quantitative or quantitative methods and CVCrBSI had to be confirmed by microbial growth from percutaneously drawn blood cultures that matched catheter cultures.  

Data collection and analysis: Patients, setting, site of insertion, colonization and CVCrBSI rates. Papers were appraised and data analyzed using CATmaker™ software.

Main results: The search produced 8 papers: One meta-analysis1 , one RCT2, and 6 observational studies3-8. One of the observational studies was excluded one due to a lack of dichotomus data8. 

The meta-analysis by Ruesch et al1, is methodologically flawed and should be ignored. The RCT by Merrer et al2, compared the subclavian site with the femoral site. The results suggested that there was a higher incidence of catheter colonization but not CVCrBSI in the subclavian group. The five cohort studies were of mixed quality. Those with level 2- suggest that again the subclavian site was associated with a lower incidence of catheter colonization but not CVCrBSI4-6. The most robust study (level 2++ evidence) by Deshpande et al suggested no significant difference in colonization or CVCrBSI rates between femoral, subclavian or internal jugular sites. However this study was restricted to an ICU population with thorough insertion and aftercare regimens. 

Reviewers conclusions: If there is excellent catheter care differences in infection rates between the insertion sites are minimal (Grade B recommendation). Otherwise the subclavian site was associated with lower rates of colonization but not of CVCrBSI, compared with either the internal jugular or femoral sites and should be considered when choosing the site of CVC insertion. The clinical significance of colonization is unclear.  There may be factors other than infection to consider when choosing insertion site.

Areas of further research: Further research into the natural history of CVCrBSI to establish the clinical importance of catheter colonization. With so many other factors determining the choice of insertion site it would be difficult to justify a large RCT to definitively determine the site with the lowest infection rate.

 Citations with links to CATs: 

  1. Ruesch S, et al. Complications of central venous catheters: Internal jugular versus subclavian access - A systematic review. Crit Care Med 2002; 30:454-460. CAT.

  2. Merrer J, et al. Complications of Femoral & Subclavian Venous Catherterization in Critically ill Patients. JAMA, 2001:286;700-707. CAT.

  3. Deshpande KS, et al. The incidence of infectious complications of central venous catheters at the subclavian, internal jugular, and femoral sites in an intensive care population. Crit Care Med. 2005;33:13-20. CAT.

  4. Richet H, et al. Prospective multicenter study of vascular-catheter-related complications and risk factors for positive central-venous catheter cultures in intensive care patients. J Clin Micro 1990;28:2520-2525. CAT.

  5. McKinley S, et al. Incidence and Predictors of Central Venous Catheter related Infection in Intensive Care Patients. Anaes Intensive Care 1999;27:164-169. CAT.

  6. Goetz AM, et al. Risk of infection due to central venous catheters: effect of site of placement and catheter type. Infect Contol Hosp Epidemiol 1998;19:842-845. CAT.

  7. Moro ML, et al. Risk factors for central venous catheter-related infections in surgical and intensive care units. Infect. Control Hosp. Epidemiol 1994;15:253-264. CAT.

  8. Sadoyama G, Filho PPG. Comparison between the jugular and subclavian vein as Insertion site for central venous catheters: Microbiological Aspects and Risk Factors for colonization and Infection. The Brazilian journal of Infectious Diseases 2003;7:142-148.

    EBM reviews CVCrBSI summary

Reviewed & Edited: DS, AL, MD, BC

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