Central Lines

Original Cochran Review http://www.ncbi.nlm.nih.gov/pubmed/22419292
shoWed Increased rate of infection with femoral lines burt suggests randomized trial
considered 83 studies for inclusion in the review. Six studies appeared eligible but five were subsequently excluded because they did not randomize participants for either site of access or catheter circumference size. One study was a high quality block randomized controlled trial. Allocation concealment was good and randomization was by a central computer. In all, 293 patients were randomized to a femoral or a subclavian CVA group. Results from this one trial were as follows. 1. CATHETER-RELATED INFECTIOUS COMPLICATIONS: Infectious complication (colonization with or without sepsis: the relative risk (RR) was 4.57 (95% confidence interval (CI) 1.95 to 10.71) favouring subclavian over femoral access. Major infectious complications (sepsis with or without bacteremia): the RR was 3.04 (95% CI 0.63 to 14.82) favouring subclavian access. Colonized catheter (greater than 103 colony-forming units/mL of gram positive microorganisms): the RR was 3.65 (95%CI 1.40 to 9.56) favouring subclavian access. Colonized catheter (greater than 103 colony-forming units/mL of gram negative microorganisms): the RR was 5.41 (95% CI 1.61 to 18.15) favouring subclavian access. 2. CATHETER-RELATED MECHANICAL COMPLICATIONS: Overall complications (arterial puncture, minor bleeding, haematoma, misplaced catheter): the RR was 0.92 (95% 0.56 to 1.51) favouring subclavian access. 3. CATHETER-RELATED THROMBOTIC COMPLICATIONS: Catheter-related thromboses (fibrin sleeves, major and complete thrombosis): the RR was 11.53 (95% CI 2.80, to 47.52) favouring subclavian access.
AUTHORS’ CONCLUSIONS:
Subclavian CVA is preferable to femoral CVA. Further trials of subclavian versus femoral or jugular CVA are needed. Research on the impact of catheter circumference on catheter-related complications is required

Subsequent randomized trial review
http://www.ncbi.nlm.nih.gov/pubmed/22809915

: 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, I = 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.
CONCLUSIONS:
: 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.

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