Complications of central venous catheters: internal jugular versus subclavian access--a systematic review.
OBJECTIVE
To test whether complications happen more often with the internal jugular or the subclavian central venous approach.


METHODS
Systematic search (MEDLINE, Cochrane Library, EMBASE, bibliographies) up to June 30, 2000, with no language restriction.


METHODS
Reports on prospective comparisons of internal jugular vs. subclavian catheter insertion, with dichotomous data on complications.


METHODS
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.


RESULTS
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.
Ruesch
Sibylle
S
Division of Anaesthesiology, Department Anaesthesiology, Pharmacology, and Surgical Intensive Care, University Hospitals of Geneva, Geneva, Switzerland.
Walder
Bernhard
B
Tramèr
Martin R
MR
D002405:Catheterization, Central Venous / Q000009:adverse effects* / Q000379:methods*; D004868:Equipment Failure / Q000706:statistics & numerical data; D006491:Hemothorax / Q000453:epidemiology / Q000209:etiology; D006801:Humans; D007601:Jugular Veins; D011030:Pneumothorax / Q000453:epidemiology / Q000209:etiology; D012306:Risk; D018805:Sepsis / Q000453:epidemiology / Q000209:etiology; D013350:Subclavian Vein; D014652:Vascular Diseases / Q000453:epidemiology / Q000209:etiology