Percutaneously inserted catheters are the most commonly used central catheters. In a prospective observational study assessing catheters placed by a critical care medicine department in a university teaching hospital, the site of insertion did not alter the risk of infection. The authors concluded that the site of insertion was not a risk factor for infection when experienced physicians insert the catheters, strict sterile technique is used, and trained intensive care unit nursing staff perform catheter care.[1]

Other studies have shown that in less controlled environments, the site of insertion is a risk factor for infection. Mermel and colleagues were able to demonstrate that the great majority of infections develop at the insertion site. Another risk factor was use of the jugular insertion site over the subclavian site.[2] In addition, for use of total parenteral nutrition, McCarthy demonstrated a similar effect.[3]

Several non-randomized studies show that the subclavian vein site is associated with a lower risk of central line-associated bloodstream infection than the internal jugular vein, but the risk and benefit of infectious and non-infectious complications must be considered on an individual basis when determining which insertion site to use. The femoral site is associated with greater risk of infection in adults, however may be limited to overweight adult patients.[4-8]

Given that teams undertaking this initiative may not yet have the processes in place to duplicate the conditions found in the Deshpande study, whenever possible the femoral site should be avoided and the subclavian line site should be preferred over the jugular and femoral sites for non-tunneled catheters in adult patients. This recommendation is based solely on the likelihood of reducing infectious complications. Subclavian placement may have other associated risks. The Central Line Bundle requirement for optimal site selection suggests that other factors (e.g., the potential for mechanical complications, the risk of subclavian vein stenosis, and catheter-operator skill) should be considered when deciding where to place the catheter. In these instances, teams are considered compliant with the bundle element as long as they use a rationale construct to choose the site.

The core aspect of site selection is the risk/benefit analysis by a physician as to whether the subclavian vein is most appropriate for the patient. There will be occasions when the physician determines that the risks and benefits of using the subclavian vein outweigh the benefits, and a different vessel is selected. For the purposes of bundle compliance, if there is dialogue among the clinical team members as to the selection site and rationale, and there is documentation as to the reasons for selecting a specific different vessel, this aspect of the bundle should be considered as in compliance. It is not the intent of the bundle to force a physician to take an action that he or she feels is not clinically appropriate.

References:

1. Deshpande KS, Hatem C, Ulrich HL, et al. The incidence of infectious complications of central venous catheters at the subclavian, internal jugular, and femoral sites in an intensive care unit population. Crit Care Med. 2005;33:13.
2. Mermel LA, McCormick RD, Springman SR, Maki DG. The pathogenesis and epidemiology of catheter-related infection with pulmonary artery Swan-Ganz catheters: A prospective study utilizing molecular subtyping. Am J Med. 1991 Sep16;91(3B):197S-205S.
3. McCarthy MC, Shives JK, Robison RJ, Broadie TA. Prospective evaluation of single and triple lumen catheters in total parenteral nutrition. J Parenter Enteral Nutr. 1987 May-Jun;11(3):259-262.
4. Goetz AM, Wagener MM, Miller JM, Muder RR. Risk of infection due to central venous catheters: Effect of site of placement and catheter type. Infect Control Hosp Epidemiol. 1998;19:842-845.
5. Parienti JJ, Thirion M, Mégarbane B, et al. Femoral versus jugular central catheterization in patients requiring renal replacement therapy: A randomized controlled study. JAMA. 2008;299:2413-2422. 
6. Richet H, Hubert B, Nitemberg G, et al. Prospective multicenter study of vascular-catheter-related complications and risk factors for positive central-catheter cultures in intensive care unit patients. J Clin Microbiol. 1990;28:2520.
7. Collignon P, Soni N, Pearson I, et al. Sepsis associated with central vein catheters in critically ill patients. Intensive Care Med. 1988;14:227.
8. Merrer J, Jonghe BD, Golliot F, et al. Complications of femoral and subclavian venous catheterization in critically ill patients. A randomized controlled trial. JAMA. 2001;286:700.