1. 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
R1.강민혜

2. 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

3. 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

4. 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

5. 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

6. 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.

7. 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

8. 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).

9. 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).

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

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

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

13. 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

14. 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

15. 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

16. Conclusion

17. Thank you !