Jean-Jacques Parienti1, Nicolas Mongardon, Bruno Mégarbane, Jean-Paul Mira, Pierre Kalfon, Antoine Gros, Sophie Marqué, Marie Thuong, Véronique Pottier, Michel Ramakers, Benoît Savary, Amélie Seguin, Xavier Valette, Nicolas Terzi, Bertrand Sauneuf, Vincent Cattoir, Leonard A Mermel, Damien du Cheyron. 1. From the Departments of Biostatistics and Clinical Research (J-J.P.), Infectious Diseases (J.-J.P.), Surgical Intensive Care (V.P.), Medical Intensive Care (A.S., X.V., N.T., B. Sauneuf, D.C.), and Microbiology (V.C.), Centre Hospitalier Universitaire (CHU) Caen, INSERM Unité Mixte de Recherche Scientifique 1075 COMETE (N.T.) and EA4655 Risques Microbiens (J.-J.P., V.C., D.C.), Université de Caen Normandie, Caen, Department of Medical Intensive Care, CHU Cochin (N.M., J.-P.M.), and Department of Medical and Toxicologic Intensive Care, CHU Lariboisière (B.M.), Paris, Department of Anesthesiology and Surgical Intensive Care, CHU Mondor, Créteil (N.M.), Department of Intensive Care Medicine, Centre Hospitalier Général, Chartres (P.K.), Department of Intensive Care Medicine, Centre Hospitalier Général, Versailles (A.G.), Department of Intensive Care Medicine, Centre Hospitalier Général, Corbeil-Essonnes (S.M.), Department of Intensive Care Medicine, Centre Hospitalier Général, Pontoise (S.M.), and Department of Intensive Care Medicine, Centre Hospitalier Général, Saint-Lô (M.R., B. Savary) - all in France; and the Rhode Island Hospital Department of Medicine, Division of Infectious Diseases, Warren Alpert Medical School of Brown University, Providence (L.A.M.).
Abstract
BACKGROUND: Three anatomical sites are commonly used to insert central venous catheters, but insertion at each site has the potential for major complications. METHODS: In this multicenter trial, we randomly assigned nontunneled central venous catheterization in patients in the adult intensive care unit (ICU) to the subclavian, jugular, or femoral vein (in a 1:1:1 ratio if all three insertion sites were suitable [three-choice scheme] and in a 1:1 ratio if two sites were suitable [two-choice scheme]). The primary outcome measure was a composite of catheter-related bloodstream infection and symptomatic deep-vein thrombosis. RESULTS: A total of 3471 catheters were inserted in 3027 patients. In the three-choice comparison, there were 8, 20, and 22 primary outcome events in the subclavian, jugular, and femoral groups, respectively (1.5, 3.6, and 4.6 per 1000 catheter-days; P=0.02). In pairwise comparisons, the risk of the primary outcome was significantly higher in the femoral group than in the subclavian group (hazard ratio, 3.5; 95% confidence interval [CI], 1.5 to 7.8; P=0.003) and in the jugular group than in the subclavian group (hazard ratio, 2.1; 95% CI, 1.0 to 4.3; P=0.04), whereas the risk in the femoral group was similar to that in the jugular group (hazard ratio, 1.3; 95% CI, 0.8 to 2.1; P=0.30). In the three-choice comparison, pneumothorax requiring chest-tube insertion occurred in association with 13 (1.5%) of the subclavian-vein insertions and 4 (0.5%) of the jugular-vein insertions. CONCLUSIONS: In this trial, subclavian-vein catheterization was associated with a lower risk of bloodstream infection and symptomatic thrombosis and a higher risk of pneumothorax than jugular-vein or femoral-vein catheterization. (Funded by the Hospital Program for Clinical Research, French Ministry of Health; ClinicalTrials.gov number, NCT01479153.).
RCT Entities:
BACKGROUND: Three anatomical sites are commonly used to insert central venous catheters, but insertion at each site has the potential for major complications. METHODS: In this multicenter trial, we randomly assigned nontunneled central venous catheterization in patients in the adult intensive care unit (ICU) to the subclavian, jugular, or femoral vein (in a 1:1:1 ratio if all three insertion sites were suitable [three-choice scheme] and in a 1:1 ratio if two sites were suitable [two-choice scheme]). The primary outcome measure was a composite of catheter-related bloodstream infection and symptomatic deep-vein thrombosis. RESULTS: A total of 3471 catheters were inserted in 3027 patients. In the three-choice comparison, there were 8, 20, and 22 primary outcome events in the subclavian, jugular, and femoral groups, respectively (1.5, 3.6, and 4.6 per 1000 catheter-days; P=0.02). In pairwise comparisons, the risk of the primary outcome was significantly higher in the femoral group than in the subclavian group (hazard ratio, 3.5; 95% confidence interval [CI], 1.5 to 7.8; P=0.003) and in the jugular group than in the subclavian group (hazard ratio, 2.1; 95% CI, 1.0 to 4.3; P=0.04), whereas the risk in the femoral group was similar to that in the jugular group (hazard ratio, 1.3; 95% CI, 0.8 to 2.1; P=0.30). In the three-choice comparison, pneumothorax requiring chest-tube insertion occurred in association with 13 (1.5%) of the subclavian-vein insertions and 4 (0.5%) of the jugular-vein insertions. CONCLUSIONS: In this trial, subclavian-vein catheterization was associated with a lower risk of bloodstream infection and symptomatic thrombosis and a higher risk of pneumothorax than jugular-vein or femoral-vein catheterization. (Funded by the Hospital Program for Clinical Research, French Ministry of Health; ClinicalTrials.gov number, NCT01479153.).
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