Insertion site of central venous catheter among hospitalized adult patients: A systematic review and network meta-analysis

Abstract

Introduction: Central venous catheterization is a commonly performed procedure, accounting for approximately 8% of hospitalized patients. Based on the current literatures, the most acceptable site for central venous catheterization is inconclusive, considering various complications in hospitalized patients. Herein, we conducted a network meta-analysis to assess the clinically important complications among internal jugular, subclavian, femoral, and peripheral insertion.

Materials and methods: The Cochrane Central Register of Controlled Trials, MEDLINE, Web of Science, Ichushi databases, Clinicaltrials.gov, and International Clinical Trials Registry Platform were searched. Studies including adults aged ≥ 18 years and randomized control trials that compared two different insertion sites (internal jugular, subclavian, femoral, and peripheral vein) were selected. The primary outcomes were clinically important infectious, thrombotic, and mechanical complications.

Results: Among the 5,819 records initially identified, 13 trials (6,201 patients) were included for a network meta-analysis. For clinically important infectious complication, subclavian insertion decreased the complication risk, compared with internal jugular [risk ratio (RR), 0.30; 95% confidence interval (CI), 0.11-0.81; moderate certainty], and femoral insertion increased than subclavian insertion (RR 2.56; 95% CI, 1.02-6.44; moderate certainty). Peripheral insertion was also significantly associated with a lower risk compared with internal jugular (RR 0.06; 95% CI, 0.01-0.32; low certainty); subclavian (RR 0.21; 95% CI, 0.05-0.77; moderate certainty); and femoral insertion (RR 0.08; 95% CI, 0.02-0.40; low certainty). For clinically important thrombotic complication, we did not find significant differences between insertion sites. For clinically important mechanical complication, femoral insertion decreased the complication risk, compared with internal jugular (RR 0.42; 95% CI, 0.21-0.82; moderate certainty) and subclavian insertion (RR 0.33; 95% CI, 0.16-0.66; moderate certainty). Peripheral insertion was also associated with the lower complication risk compared with internal jugular (RR 0.39; 95% CI, 0.18-0.85; low certainty) and subclavian insertion (RR 0.31; 95% CI, 0.13-0.75; moderate certainty).

Conclusion: The insertion site of the central venous catheter, which is most likely to cause the fewest complications, should be selected. Our findings can provide the rationale for deciding the insertion site for a central venous catheter.

Systematic review registration: [www.protocols.io], identifier [61375].

Keywords: central venous catheter; complication; hospitalization; insertion site; network meta-analysis.

FIGURE 1

Flow diagram of studies included in this review. *Ichushi is a database of Japanese research papers. CENTRAL, cochrane central register of controlled trials; ICTRP, international clinical trials registry platform; MEDLINE, medical literature analysis and retrieval system on line; WHO, world health organization.

FIGURE 2

(A) Clinically important infectious complication. (B) Clinically important thrombotic complication. (C) Clinically important mechanical complication. Network plot for central venous access sites for hospitalized patients. When randomized control trials (RCTs) for direct comparisons exist, this is shown by connections between nodes. The size of the node represents the number of participants who received the intervention. The thickness of lines connecting nodes represents the number of trials for that comparison. PICC, peripherally inserted central venous catheter; RCT, randomized controlled trial.

FIGURE 3

(A) Clinically important infectious complication. (B) Clinically important thrombotic complication. (C) Clinically important mechanical complication. Forest plots for association of central venous access sites with study outcomes. All outcomes are reported as network risk ratios and absolute risk differences with 95% confidence intervals (CIs). For estimating risk ratios for the comparison of peripherally inserted central venous catheter (PICC) vs. Internal jugular and PICC vs. Femoral, only indirect evidence was used, when no direct pair-wise comparisons were available. The estimated absolute risk was calculated based on the incidence of each outcome in patient allocated to the control group. CI, confidence interval; PICC, peripherally inserted central venous catheter.

FIGURE 4

(A) Internal jugular insertion. (B) Subclavian insertion. (C) Femoral insertion. (D) Peripherally inserted central venous catheter (PICC). Radar chart plot of surface under the cumulative ranking curve (SUCRA) value of each complication among central venous access sites. The SUCRA value in reducing infectious complication was higher for peripherally inserted central venous catheter (PICC) (99.5), followed by subclavian (65.9), femoral (26.2), and internal jugular insertion (8.5). For thrombotic complication, subclavian insertion showed higher SUCRA value (77.8), followed by PICC (59.8), internal jugular (40.6), and femoral insertion (21.8). For mechanical complication, PICC showed higher SUCRA value (83.8), followed by femoral (82.2), internal jugular (27.3), and subclavian insertion (6.6). PICC, peripherally inserted central venous catheter; SUCRA, surface under the cumulative ranking curve.