Marik PE, Flemmer M, Harrison W: The risk of catheter-related bloodstream infection with femoral venous catheter as compared to subclavian and internal jugular venous catheters: a systematic review of the literature and meta-analysis. Crit Care Med. 2012, 40: 2479-2485.
Why this study is important
Placing central venous catheters in critically ill patients is one of the most common interventions made in the emergency department. While we don’t often see the complications of these interventions, understanding best practice for our patients can lead to improved outcomes and prevention of serious bloodstream infections later in our patients’ hospital courses.
What we already know about the topic
Previous studies have shown that there is a significant increase in rates of infection for femoral central venous catheter vs internal jugular and subclavian placement. Because of the evidence in these prior studies, the CDC and the IDSA have made the recommendation level 1A in favor of avoiding femoral CVCs whenever possible.
Brief overview of the study
The study is a meta-analysis of randomized controlled trials and cohort studies that examined the frequency of bloodstream infections secondary to catheter placement between femoral, internal jugular and subclavian sites. Results from the studies were individually analyzed to determine the risk ratio for infection based on site of CVC placement, and these were further analyzed for heterogeneity of results, which would indicate a poor study design. Results showed that when the two studies with the greatest heterogeneity were excluded, there was no significant difference in the infection risk ratio between the three possible sites. There was also a correlation between the age of the study and the risk of infection in femoral placement (older studies had higher rates of infection).
The study was limited by several factors, including that there were only ten studies that qualified for inclusion. Meta-analyses are also intrinsically limited by the fact that the methods used in each individual study are not going to conducted exactly the same. Additionally, the fact that it was necessary to do statistical analyses in order to remove two of the studies to reach their conclusion that there was no difference is concerning.
Take home points
Femoral central venous catheters may not have as much increased risk of infection as previously thought, and infections have decreased in recent years due to increased hospital precautions.