Central venous access sites to prevent venous blood clots, blood vessel narrowing and infection in patients requiring long-term intravenous therapy

Hamilton HC, Foxcroft D

Published Online:

April 16, 2008

Central venous access (CVA) involves a large bore long-term use catheter routed through a vein in the neck, upper chest or groin (femoral) area, to give drugs that cannot be given by mouth or via a conventional needle (or tube (cannula) in the arm over the longer term. This review examined whether there was any evidence to show that CVA through any one site (neck, upper chest or femoral area) was better than any other. Results from one high quality randomized trial indicated that the upper chest area was better than the femoral area because of a lower risk of infection and blood clots forming on the catheter tip. No studies compared the neck access site with other sites so no conclusions can be drawn about the relative advantages or disadvantages of access in the neck.

Abstract (click to read)

Background:

Central venous access (CVA), in which a large bore catheter is routed through a vein in the neck, upper chest or femoral area, is needed to give drugs that cannot be given by mouth or via a conventional cannula in the arm.

Objectives:

To establish whether either the jugular, subclavian or femoral CVA routes result in a lower incidence of venous thrombosis, venous stenosis or infection related to CVA devices.

To determine whether the circumference of a long-term central venous access device influences the incidence of venous thrombosis, venous stenosis or infection related to CVA devices.

Search strategy:

We searched the Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library 2006, Issue 4), MEDLINE, CINAHL, EMBASE (from inception to December 2006), reference lists of identified trials, and bibliographies of published reviews. We also contacted researchers in the field. There were no language restrictions.

Selection criteria:

We included randomized controlled trials comparing central venous catheter insertion routes.

Data collection and analysis:

Two authors assessed potentially relevant studies. We resolved disagreements by discussion. Relevant outcomes were: venous thrombosis, venous stenosis, infection related to CVA devices, mechanical complications (e.g misplaced catheter, minor bleeding, haematoma).

Main results:

We considered 83 studies for inclusion in the review. Six studies appeared eligible but five were subsequently excluded because they did not randomize participants for either site of access or catheter circumference size. One study was a high quality block randomized controlled trial. Allocation concealment was good and randomization was by a central computer. In all, 293 patients were randomized to a femoral or a subclavian CVA group. Results from this one trial were as follows

1. Catheter-related infectious complications
Infectious complication (colonization with or without sepsis: the relative risk (RR) was 4.57 (95% confidence interval (CI) 1.95 to 10.71) favouring subclavian over femoral access.
Major infectious complications (sepsis with or without bacteremia): the RR was 3.04 (95% CI 0.63 to 14.82) favouring subclavian access.
Colonized catheter (greater than 103 colony-forming units/mL of gram positive microorganisms): the RR was 3.65 (95%CI 1.40 to 9.56) favouring subclavian access.
Colonized catheter (greater than 103 colony-forming units/mL of gram negative microorganisms): the RR was 5.41 (95% CI 1.61 to 18.15) favouring subclavian access.

2. Catheter-related mechanical complications
Overall complications (arterial puncture, minor bleeding, haematoma, misplaced catheter): the RR was 0.92 (95% 0.56 to 1.51) favouring subclavian access.

3. Catheter-related thrombotic complications
Catheter-related thromboses (fibrin sleeves, major and complete thrombosis): the RR was 11.53 (95% CI 2.80, to 47.52) favouring subclavian access.

Authors' conclusions:

Subclavian CVA is preferable to femoral CVA. Further trials of subclavian versus femoral or jugular CVA are needed. Research on the impact of catheter circumference on catheter-related complications is required.

This record should be cited as:

Hamilton HC, Foxcroft D. Central venous access sites for the prevention of venous thrombosis, stenosis and infection in patients requiring long-term intravenous therapy. Cochrane Database of Systematic Reviews 2007, Issue 3. Art. No.: CD004084. DOI: 10.1002/14651858.CD004084.pub2

Assessed as up to date:

April 17, 2007

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Primary Review Group:

Anaesthesia Group

Health topics:

Anaesthesia & pain control > Post-anaesthetic unit/intensive care unit > Circulatory care

Cochrane Summaries^beta

Independent high-quality evidence for health care decision making

Central venous access sites to prevent venous blood clots, blood vessel narrowing and infection in patients requiring long-term intravenous therapy

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