Cumulative Evidence of Randomized Controlled and Observational Studies on Catheter-Related Infection Risk of Central Venous Catheter Insertion Site in ICU Patients: A Pairwise and Network Meta-Analysis

Crit Care Med. 2017 Apr;45(4):e437-e448. doi: 10.1097/CCM.0000000000002092.

Abstract

Background: Selection of central venous catheter insertion site in ICU patients could help reduce catheter-related infections. Although subclavian was considered the most appropriate site, its preferential use in ICU patients is not generalized and questioned by contradicted meta-analysis results. In addition, conflicting data exist on alternative site selection whenever subclavian is contraindicated.

Objective: To compare catheter-related bloodstream infection and colonization risk between the three sites (subclavian, internal jugular, and femoral) in adult ICU patients.

Data source: We searched MEDLINE, EMBASE, Cochrane Central Register of Controlled trials, CINAHL, and ClinicalTrials.gov.

Study selection: Eligible studies were randomized controlled trials and observational ones.

Data extraction: Extracted data were analyzed by pairwise and network meta-analysis.

Data synthesis: Twenty studies were included; 11 were observational, seven were randomized controlled trials for other outcomes, and two were randomized controlled trials for sites. We evaluated 18,554 central venous catheters: 9,331 from observational studies, 5,482 from randomized controlled trials for other outcomes, and 3,741 from randomized controlled trials for sites. Colonization risk was higher for internal jugular (relative risk, 2.25 [95% CI, 1.84-2.75]; I = 0%) and femoral (relative risk, 2.92 [95% CI, 2.11-4.04]; I = 24%), compared with subclavian. Catheter-related bloodstream infection risk was comparable for internal jugular and subclavian, higher for femoral than subclavian (relative risk, 2.44 [95% CI, 1.25-4.75]; I = 61%), and lower for internal jugular than femoral (relative risk, 0.55 [95% CI, 0.34-0.89]; I = 61%). When observational studies that did not control for baseline characteristics were excluded, catheter-related bloodstream infection risk was comparable between the sites.

Conclusions: In ICU patients, internal jugular and subclavian may, similarly, decrease catheter-related bloodstream infection risk, when compared with femoral. Subclavian could be suggested as the most appropriate site, whenever colonization risk is considered and not, otherwise, contraindicated. Current evidence on catheter-related bloodstream infection femoral risk, compared with the other sites, is inconclusive.

Publication types

  • Comparative Study
  • Meta-Analysis
  • Review

MeSH terms

  • Catheter-Related Infections / epidemiology*
  • Catheter-Related Infections / etiology
  • Catheterization, Central Venous / adverse effects*
  • Catheterization, Central Venous / methods*
  • Femoral Vein
  • Humans
  • Intensive Care Units*
  • Jugular Veins
  • Network Meta-Analysis
  • Observational Studies as Topic
  • Randomized Controlled Trials as Topic
  • Risk Factors
  • Sepsis / epidemiology*
  • Sepsis / etiology
  • Subclavian Vein