Where Should I Place My Central Line?

by Joseph Esherick, M.D., FAAFP, FHM

The internal jugular or subclavian veins have fewer combined mechanical or infectious complications for central venous catheter insertions compared with femoral vein CVC placements.  Numerous organizations have proposed guidelines or central line bundles that have advocated preferential use of the internal jugular vein (IJ) or subclavian vein (SCV) over the femoral vein for central venous catheter (CVC) insertions. The organizations that recommend this include the Center for Disease Control, Society for Healthcare Epidemiology of America, Infectious Disease Society of America, Insitutue for Healthcare Improvement, Joint Commission and the American Society of Anesthesiologists.  The IHI, Joint Commission and SHEA/IDSA central line bundles all state to "avoid the femoral vein for inserting central venous catheters in adults."

The incidence of symptomatic DVTs for subclavian vein CVCs vs IJ CVCs vs femoral CVCs is 0.5%, 0.9% and 1.4%, respectively.  Femoral lines have twice the rate of DVTs compared with IJ lines and three times the rate of DVTs compared with SCV CVCs.  In addition, hematoma formation occurs twice as frequently in femoral CVCs compared with IJ CVCs.  The one complication that is higher in landmark-guided infraclavicular SCV lines is pneumothorax which occurs 1.5% of the time vs 0.5% in IJ lines (includes both landmark-guided IJ and ultrasound-guided IJ lines).  This pneumothorax risk is markedly reduced with ultrasound-guided axillary vein CVC placement, supraclavicular SCV lines and ultrasound-guided IJ lines.

For catheter-related bloodstream infections (CRBSIs), the rate for subclavian vein CVCs vs IJ CVCs vs femoral CVCs is 1.5 vs 3.6 vs 4.6 cases per 1,000 catheter days.  The risk of CLABSI for femoral CVCs is especially high if adults have a BMI>28.  The combined rate of CLABSI or symptomatic DVTs is higher for femoral CVC vs SCV CVC  (HR 3.5, p = 0.003).  A new systematic review of central venous catheter placement concluded that there is no difference in CLABSI in recent studies for CVCs in the three locations; however, the majority of the evidence and all the association guidelines favor subclavian or internal jugular vein central line placement over femoral line placement because of a trend towards increased infection rate and an increased risk of DVTs.

Sources:

  1. Parienti JJ et al.  Femoral vs jugular venous catheterization and risk of nosocomial events in adults requiring acute renal replacement therapy: a randomized controlled trial.  JAMA. 2008 May 28;299(20):2413-22
  2. Timsit JF et al. Jugular versus femoral short-term catheterization and risk of infection in intensive care unit patients. Causal analysis of two randomized trials.  Am J Respir Crit Care Med. 2013 Nov 15;188(10):1232-9.
  3. Parienti JJ et al.  Intravascular Complications of Central Venous Catheterization by Insertion Site.  N Engl J Med. 2015 Sep 24;373(13):1220-9.
  4. Lorente L et al.  Central venous catheter-related infection in a prospective and observational study of 2,595 catheters. Crit Care. 2005;9(6):R631-5.
  5. Practice Guidelines for Central Venous Access 2020: An Updated Report by the American Society of Anesthesiologists Task Force on Central Venous Access. Anesthesiology. 2020; 132 (1): 8-43