Intravascular Complications of Central Venous Catheterization by Insertion Site Jean‑Jacques Parienti, M.D., Ph.D., Nicolas Mongardon, M.D., Bruno Mégarbane, M.D. NEJM September 24, 2015 2015-11-19 R1.강민혜

Introduction Central catheterization Subclavian, jugular, and femoral central venous catheterization are associated with infectious, thrombotic, and mechanical complications Catheter-related bloodstream infection Significant effect on morbidity, mortality, health care costs Extraluminal microbial colonization of the insertion site Colonization is also associated with thrombosis

Introduction Although the importance of catheter-related deep-vein thrombosis (DVT) has been debated, all thromboses have the potential to embolize Catheter-related DVT & PTE may remain undiagnosed in critically ill patients undergoing mechanical ventilation We conducted the 3SITES multicenter study Risk of catheter-related BSI or Symptomatic catheter-related DVT in adult patients In ICU Hypothesis : The risk of these major complications would differ according to the site of catheter insertion

Methods “3SITES study” Participants Multicenter randomized, controlled trial 4 university affiliated hospitals and 5 general hospitals -> 10 ICUs in France December 2011 ~ June 2014. Participants > 18 years of age Admitted to the ICU, Nontunneled central venous vascular access through a new venipuncture suitable for at least two of the following three sites : Subclavian, jugular, femoral veins

Methods “3SITES study” If all three venous access sites (subclavian, jugular, femoral) were considered suitable for catheter placement → The site was assigned in a 1:1:1 randomization (three-choice scheme) If one of the three sites was not suitable on both the left and right sides → The site was assigned in a 1:1 randomization scheme for the other two sites (two-choice scheme) If only one site was suitable → that catheterization procedure was not included in the study

Methods “3SITES study” Trial Procedures Maximal sterile barrier precautions After catheterization (Jugular, subclavian) -> chest radiography After Removal -> tip culture, peripheral culture compression ultrasonography -> r/o DVT surgical hand antisepsis,17 sterile gloves, surgical long-sleeved gowns, caps, and masks. Patients were covered by sterile drapes.

Methods “3SITES study” Outcomes Primary outcome Secondary outcome Incidence of major catheter-related complications from the time of catheter insertion to 48 hours after catheter removal Major complications : catheter-related BSI (2 Blood culture microorganism = catheter tip culture) symptomatic DVT (compression ultrasonography) Secondary outcome catheter-tip colonization total DVT after catheter removal Mechanical complications during insertion

Methods -screening & Randomization 3027 patients, 3471 catheter (1284 jugular, 1171 femoral, 1016 subclavian) 2532 (72.9%) three choice scheme (845 jugular, 844 femoral, 843 subclavian) Catheters were inserted in the randomly assigned site and side in 3154 cases (90.9%) overall, including 866 cases (85.2%) assigned to the subclavian site, 1174 cases (91.4%) assigned to the jugular site, and 1114 cases (95.1%) assigned to the femoral site (Fig. 1).

Results -baseline characteristics Three-choice comparison, three pairwise comparison간에 Primary outcome에 영향을 줄 수 있는 basline characteristics에 관한 표인데,각 그룹간의 유의한 차이는 없다. ‡ SAPS II denotes Simplified Acute Physiology Score II (values range from 0 to 163 points, with higher scores indicating a higher risk of death).

Results Anatomic landmark사용: subclavian, femoral >jugular Catheterization속도: femoral > Alcohol based product 사용은 비슷

Results In pairwise comparisons for the primary outcome in groups from the three-choice and two-choice schemes combined, Primary outcome: femoral `=. Jugular >> subclavian

Results In the three-choice comparison, there were 50 nonduplicate primary outcome events. 8 subclavian, 20 jugular, 22 femoral

Discussion The overall risk of mechanical, infectious, and thrombotic complications was similar among the three insertion sites Catheterization of the subclavian v. >> femoral, jugular ↓ catheter-related BSI or Symptomatic catheter-related DVT ( subcutaneous course before entry into the vein is longer -> low bacterial bioburden) ↑ mechanical complications limited by ultrasonographic guidance Pneumothorax: can be diagnosed, treated immediately

Discussion Limitation Use of ultrasonographic guidance during insertion: not randomized No daily chlorhexidine bathing and chlorhexidine-impregnated dressing → may have influenced the risk of mechanical and infectious complications PICC(peripherally inserted central venous catheters) → infection, high risk of thrombosis

Conclusion In the 3SITES study, catheterization of the subclavian vein a lower risk of catheter-related bloodstream infection and symptomatic deep-vein thrombosis >> jugular or femoral vein. But, higher risk of mechanical complications, primarily pneumothorax

Conclusion

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