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Femoral vs. Internal Jugular vs. Subclavian line placement in ICU

In intensive care patients, with good insertion technique and aftercare there is no statistically significant difference in rates of catheter colonization or CVCrBSI when comparing femoral, internal jugular or subclavian sites

Level of evidence: 2++ (Cohort study with a very low risk of bias)

 

Citation/s: 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.
Lead author's name and fax: Kedar S Deshpande. Montefiore Medical Center, The Albert Einstein College of Medicine.

 

Three-part Clinical Question: In critically ill patients, does the choice of CVC site, affect the incidence of CVC colonization or CVCrBSI.
 

Search Terms: See summary

 

The Study: Cohort Study.
 

The Study Patients: ICU patients, no exclusions. Single ICU. Experienced clinicians choosing what they considered to be the most appropriate site for CVC. Strict insertion and aftercare protocols. CVCs removed if there was a suspicion of infection, CVC no longer require, or after 14 days irrespective of site. Definitions of colonization and CVCrBSI clear and in-keeping with census opinion. All patients similar
 

Exposure of Interest: Catheterization at the femoral, internal jugular or subclavian site.
 

The Outcome: CVCrBSI or catheter colonization.
Subjects were defined and similar in other important ways. The exposures and outcomes were either objective or measured blind. Follow-up was long enough; follow-up was complete enough.

The Evidence:

 

 

Subclavian

(n=221)

Int. Jugular

(n=191)

Femoral

(n=139)

p

CVCrBSI (%)

0.45

0

1.44

0.2635

Colonization(%)

0.45

1.05

2.88

0.1338

 

 

EBM questions:

 

1.      Do the methods allow accurate testing of the hypothesis? Yes. A well conducted observational study. Patient characteristics were similar across the sites.

2.      Do the statistical tests correctly test the results to allow differentiation of statistically significant results? Yes.

3.      Are conclusions valid in light of the results? Yes. No significant difference in infection rates between the 3 sites.

4.      Did results get omitted, and why? No.

5.      Did they suggest areas of further research? No.

6.      Did they make any recommendations based on the results and were they appropriate? Yes. All three catheter sites are safe in the ICU as long as the catheters are well cared for. This is especially true for the femoral site. As a result they recommended that femoral catheters should be avoided in non-ICU patients were optimal catheter care would be more difficult to achieve.

7.      Is the study relevant to my clinical practice? Yes.

8.      What level of evidence does this study represent? 2++

9.      What grade of recommendation can I make on this result alone? B

10.  What grade of recommendation can I make when this study is considered along with other available evidence? B

11.  Should I change my practice because of these results? Yes. We should adopt similar intense catheter care protocols, especially when using the femoral site.

12.  Should I audit my current practice because of these results? Yes.

 

Appraised by: Dr Chris Cairns, Consultant, ICU, Stirling Royal Infirmary; 01 June 2005
Email: Chris.Cairns@fvah.scot.nhs.uk


Kill or update By: June 2010

 

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