Dedicated to Richar Haydon.
A 2012 study published in Critical Care Medicine caused a huge change in views on use of femoral CVCs as it showed that blood steam infection rates were not higher using this site.
A recent French RCT published in the NEJM in September 2015 (and reviewed this week in Medscape), compared complications of CVC insertion in the 3 most commonly used sites - Internal Jugular (IJ), Subclavian (SC) and Femoral (F).
This multi-centre study was not a small. It involved 3471 catheters inserted in 3027 patients, in 10 ICUs (in 9 hospitals) over a 2.5 year period.
The primary outcome measure was a composite of catheter-related bloodstream infection and symptomatic deep-vein thrombosis (they also looked at the incidence of pneumothorax).
The risk for the primary outcome was similar in the F and IJ groups (hazard ratio [HR], 1.3; P = 0.30) and significantly higher in both F and IJ groups compared with the SC group (HR, 3.5 and 2.1, respectively). Pneumothorax requiring a chest tube was associated with 1.5% of SC vein insertions and 0.5% of IJ vein insertions.
The bottom line:
Overall, SC vein catheterisation was associated with a lower risk for catheter-related bloodstream infection and symptomatic DVT, and a higher risk for pneumothorax, than IJ or F vein catheterisation.
Personally, especially in my retrieval work, where the risk of pneumothorax can have devastating consequences, I will continue to use the Femoral vein where possible (the list of exclusions would be long - severe hypovolemic shock in trauma, beriatric patients and site infection / irritation, to mention a few). A Femoral CVC can be changes to SC CVC once the patient is in ICU and there is less time pressure.
Enjoy,
Danny Ben-Eli
@danbeneli
Emergency Physician
A 2012 study published in Critical Care Medicine caused a huge change in views on use of femoral CVCs as it showed that blood steam infection rates were not higher using this site.
A recent French RCT published in the NEJM in September 2015 (and reviewed this week in Medscape), compared complications of CVC insertion in the 3 most commonly used sites - Internal Jugular (IJ), Subclavian (SC) and Femoral (F).
This multi-centre study was not a small. It involved 3471 catheters inserted in 3027 patients, in 10 ICUs (in 9 hospitals) over a 2.5 year period.
The primary outcome measure was a composite of catheter-related bloodstream infection and symptomatic deep-vein thrombosis (they also looked at the incidence of pneumothorax).
The risk for the primary outcome was similar in the F and IJ groups (hazard ratio [HR], 1.3; P = 0.30) and significantly higher in both F and IJ groups compared with the SC group (HR, 3.5 and 2.1, respectively). Pneumothorax requiring a chest tube was associated with 1.5% of SC vein insertions and 0.5% of IJ vein insertions.
The bottom line:
Overall, SC vein catheterisation was associated with a lower risk for catheter-related bloodstream infection and symptomatic DVT, and a higher risk for pneumothorax, than IJ or F vein catheterisation.
Personally, especially in my retrieval work, where the risk of pneumothorax can have devastating consequences, I will continue to use the Femoral vein where possible (the list of exclusions would be long - severe hypovolemic shock in trauma, beriatric patients and site infection / irritation, to mention a few). A Femoral CVC can be changes to SC CVC once the patient is in ICU and there is less time pressure.
Enjoy,
Danny Ben-Eli
@danbeneli
Emergency Physician
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