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Three Part Question

In [patients undergoing central venous catheterisation] is the [internal jugular or the subclavian approach] associated with [better outcomes]?

Clinical Scenario

A 50 year old non-insulin dependent diabetic presents to the Emergency Department with a three day history of fever, acute confusion and lethargy. On assessment you find him in septic shock and commence peripheral fluid resuscitation. As part of the early goal directed management of this man you need to place a central venous catheter but wonder which route will be more successful and produce less complications.

Search Strategy

1. Medline 1950 to May 2007 using the OVID interface
2. Cochrane database of systematic reviews.
[catherisation.mp OR exp catheterization/ OR exp catherization, central venous/ OR central venous.mp OR central vein catheteri$.mp OR central lin$.mp] AND [(exp jugular veins/ OR internal jugula$.mp) AND (exp subclavian vein/ OR subclavian vein.mp)] LIMIT to human and English language.

Search Outcome

Altogether 561 papers were produced by searching from 1950. Once the systematic review was identified, we limited our search to publications after this date involving humans and published in English. This produced 128 papers none of which helped answer our question.

Relevant Paper(s)

Author, date and country	Patient group	Study type (level of evidence)	Outcomes	Key results	Study Weaknesses
Ruesch 2002 Switzerland		Systematic review	Arterial puncture	Jugular 3.0% vs. Subclavian 0.5%. Relative risk 4.7 (95%CI 2 to 10)	Whilst appropriate search terms were used, and additionally searched in languages other than English, the exact search strategy was not published.
			Catheter malposition	Jugular 5.3% vs. Subclavian 9.3%. Relative risk 0.66 (95%CI 0.44 to 0.99)
			Haemo/pneumothorax	Jugular 1.3% vs. Subclavian 1.5%. Relative risk 0.76 (95%CI 0.43 to 1.33)
			Bloodstream infection	Jugular 8.6% vs. Subclavian 4.0%. Relative risk 2.24 (95%CI 0.62 to 8.09)

Comment(s)

The systematic review was well conducted but found no randomised trials to answer the question. The authours have analysed a number of propsective cohort studies that have published dichotomous results for the outcomes concerned. They found little difference between the two sites in terms of early and late complications. The authors concluded that randomised trials are required.

Clinical Bottom Line

There appears to be no difference between the jugular and subclavian vein approaches for central vein catheterisation. In an individual patient, the approach to choose should probably be the one you have most successful experience with (although a case could be made for the opposite!).

Level of Evidence

Level 1 - Recent well-done systematic review was considered or a study of high quality is available.

References

1. Ruesch S, Walder B, Tramer MR. Complications of central venous catheters: internal jugular versus subclavian access - a systematic review. Crit Care Med 2002; 30:454-460