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Complications of Femoral and Subclavian Venous Catheterization in Critically Ill Patients: A Randomized Controlled Trial - Complications of Femoral and Subclavian Venous Catheterization in Critically Ill Patients: A Randomized Controlled Trial
Description:
Complications of Femoral and Subclavian Venous Catheterization in Critically Ill Patients: A Randomized Controlled Trial.
Hypothesis:
The objective of this study was to compare complication rates of subclavian venous catheterization and femoral venous catheterization.
Study Design
Study Design:
Patients Enrolled: 289
Drug/Procedures Used:
Patients admitted to four university-affiliated intensive care units (ICU) and to four general hospitals ICU and requiring central venous catheterization were randomized to subclavian catheterization (145 patients) or to femoral catheterization (144 patients). The following clinical endpoints were analyzed. 1) Mechanical complications including arterial puncture, pneumothorax, hemothorax or mediastinal hematoma, misplacement of the catheter tip, hematoma or bleeding, air embolism. 2) Catheter-related infections assessed through cultures of the catheter tip. 3) Catheter-related thrombosis assessed by systematic compression sonography and duplex Doppler ultrasonograhy. Clinical predictors of each complication were evaluated using logistic regression anlaysis and Cox proportional hazard modeling.
Principal Findings:
Mechanical complications occurred in 17.3% of patients in the femoral group and 18.8% of patients in the subclavian group (p=0.74). The most common mechanical complications were arterial puncture (7%), minor bleeding (4.5%) and minor hematoma (1.0%). Two major hematoma occurred in the femoral catheterization group and four pneumothoraces occurred in the subclavian group. Multivariate analysis identified duration of catheterization, catheter insertion at two of the participating centers and catheter insertion during the night as independent predictors of mechanical complications. Infection complications were analyzed in 93.4% of patients. The incidence of catheter-related infections was 19.8% in the femoral group and 4.5% in the subclavian group (p<0.001). There were six major catheter-related infections complications in the femoral group (4.4%) and two in the subclavian group (1.5%, p=0.07). Insertion of the catheter at the femoral site was identified as independent predictor of catheter-related infections, while use of the catheter for administration of antibotics was protective. Thrombotic complications occurred in 21.5% of patients in the femoral group and 1.9% of patients in the subclavian group (p<0.001). There were seven major catheter-related thromboses in the femoral group and none in the subclavian group (6% vs 0%, p=0.01). Multivariate analysis identified femoral vein catheterization as the only independent predictor of thrombotic complications.
When compared with subclavian vein catheterization, femoral vein catheterization is associated with a significantly higher incidence of catheter-related infections and thrombotic complications.
Interpretation:
This study brings attention to the relatively high incidence of complications associated with central vein catheterization and particularly with femoral vein catheterization. In addition, it highlights the importance of operator experience. The high complication rate observed in this study and the doubtful benefit of pulmonary artery catheterization identified by other studies support a strategy of carefully weighing the risk vs. benefit of central vein catheterization, particularly when performed for pulmonary artery catheter placement.
References:
1. Merrer J, De Jonghe B, Golliot F, et al. for the French Catheter Study Group in Intensive Care. JAMA 2001;286:700-7.
Keywords: Hemothorax, Multivariate Analysis, Pneumothorax, Femoral Vein, Hematoma, Pulmonary Artery, Catheterization, Swan-Ganz, Catheterization, Central Venous, Subclavian Vein, Proportional Hazards Models, Thrombosis, Critical Illness, Embolism, Air, Catheter-Related Infections, Logistic Models
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