Objective : To test whether complications happen more often with the internal jugular or the subclavian central venous approach.
Data Source : Systematic search (MEDLINE, Cochrane Library, EMBASE, bibliographies) up to June 30, 2000, with no language restriction.
Study Selection : Reports on prospective comparisons of internal jugular vs. subclavian catheter insertion, with dichotomous data on complications.
Data Extraction : No valid randomized trials were found. Seventeen prospective comparative trials with data on 2,085 jugular and 2,428 subclavian catheters were analyzed. Meta-analyses were performed with relative risk (RR) and 95% confidence interval (CI), using fixed and random effects models.
Data Synthesis : In six trials (2,010 catheters), there were significantly more arterial punctures with jugular catheters compared with subclavian (3.0% vs. 0.5%, RR 4.70 [95% CI, 2.05-10.77]). In six trials (1,299 catheters), there were significantly less malpositions with the jugular access (5.3% vs. 9.3%, RR 0.66 [0.44-0.99]). In three trials (707 catheters), the incidence of bloodstream infection was 8.6% with the jugular access and 4.0% with the subclavian access (RR 2.24 [0.62-8.09]). In ten trials (3,420 catheters), the incidence of hemato- or pneumothorax was 1.3% vs. 1.5% (RR 0.76 [0.43-1.33]). In four trials (899), the incidence of vessel occlusion was 0% vs. 1.2% (RR 0.29 [0.07-1.33]).
Conclusions : There are more arterial punctures but less catheter malpositions with the internal jugular compared with the subclavian access. There is no evidence of any difference in the incidence of hemato- or pneumothorax and vessel occlusion. Data on bloodstream infection are scarce. These data are from nonrandomized studies; selection bias cannot be ruled out. In terms of risk, the data most likely represent a best case scenario. For rational decision-making, randomized trials are needed.
Central venous catheters (CVCs) are essential for the clinical management of many patients. Indications for a CVC are the intravenous administration of specific drugs (e.g., catecholamines), parenteral nutrition, hemodialysis, and hemodynamic monitoring. In many institutions, patients undergoing major surgery and patients with critical illness or cancer routinely receive a CVC. Thus, percutaneous placement of a catheter into a central vein is a frequent procedure in many clinical settings. At the Geneva University Hospitals, 35,087 patients were hospitalized in 1998, and 2,848 CVCs were used in that year. If we assume that none of the patients received more than one CVC, then 8.1% of all hospitalized patients had a CVC.
The most frequently used anatomical sites for CVC insertion are the internal jugular and the subclavian vein (1). However, in an individual patient, criteria for choosing one approach over the other often remain unclear. This choice could depend on the complication rate with each approach. Indeed, there is a substantial risk of mechanical lesions (e.g., arterial puncture, pneumothorax, cardiac tamponade, or nerve lesions) and thrombotic or septic complications with each CVC. These complications are related to the procedure of the insertion or to the catheter itself. An improved understanding of CVC-related risks might help clinicians to choose one approach over the other in specific clinical settings. The aim of this quantitative systematic review was to gather the best available evidence on the risks related to internal jugular and subclavian central venous catheterization, to critically appraise and synthesize the data, and to quantify the different risks.