Central venous access in intensive care unit patients: is the subclavian vein the royal route?

Abstract

Central venous catheter insertion is required in many critically ill patients. Selection of the insertion site should be based on both the ease and risks of the procedure. These last include infection, thrombosis and mechanical complications. As compared to the subclavian vein, the internal jugular vein has been associated with a significantly higher risk of infection in observational studies [1]. A recent prospective randomised study of 289 adult ICU patients compared the subclavian approach to the femoral approach. Higher rates of significant catheter colonisation (19.8% versus 4.5%, p<0.001) and catheter-related bloodstream infection (4.4% vs 1.5%, p=0.07) were seen with the femoral approach [2]. In the same study, the risk of catheter-related thrombosis was independently associated with use of the femoral approach (21.5% versus 1.9%, p<0.001), and complete thrombosis was diagnosed in 6% of patients in the femoral group versus none in the subclavian group (p=0.01). Consequently, prophylaxis of deep venous thrombosis should be given when the femoral approach is used [3]. Similarly, the risk of catheter-related thrombosis in ICU patients was more than 4 times higher when the catheter was inserted into the internal jugular vein, as compared to the subclavian vein [4]. Clearly, the risks of thrombosis and infection are lower with the subclavian approach than with the untunnelled internal jugular or femoral approaches. These results indicate that, in patients expected to require a central venous catheter for longer than 5–7 days, the subclavian vein should be preferred, provided the risk of mechanical complications is low.