Central Line Insertion Site and Ultrasound Guidance

Washington University Emergency Medicine Journal Club- March 2021

This month at journal club we discussed risks of infectious, thrombotic, and mechanical complications based on central venous catheter site, as well as the benefits of ultrasound guidance for internal jugular line placement. Thanks to Drs. Wallace and Ablordeppey for leading the discussion on this interesting topic.


You are working a shift in TCC one busy afternoon when a patient is brought in by EMS for lethargy and a fever.  You enter the room the find a 65-year-old female with a history of hypertension, GERD, and a recent hospitalization for pneumonia for which she left AMA for a family emergency after 2 hospital days. She now complains of cough, weakness, and fever for the last 3 days.  

On physical exam, you note a temperature of 39 degrees Celsius, a heart rate of 128, a blood pressure of 77/40, a respiratory rate of 28, and an oxygen saturation of 92% on room air.  Aside from mild coarse breath sounds and tachycardia, the remainder of the exam is normal.  

Recognizing that the patient has at least 2 SIRS criteria, you order a set of labs that include a CBC, BMP, serum lactate, blood cultures, and a CXR.  The lactate is run as a point of care and comes back at 6.4 mmol/L.  

You order 30mg/kg of lactated ringers via pressure bag and after the infusion her heart rate is 125 and blood pressure is 84/50. Her x-ray shows a denser right middle lobe infiltrate. You realize quickly that the patient meets criteria for septic shock.  You immediately order antibiotics and more fluids while awaiting the lab results, but wonder what other interventions should be instituted.  You remember reading about sepsis bundles and wonder if you should obtain central IV access to begin vasopressors. After talking to your attending, you decide that a CVC is warranted. You consider where to place the catheter and whether ultrasound guidance would be helpful.  

You decide to place a right internal jugular CVC under ultrasound guidance. The CVC is placed without any complications and the patient is admitted to the ICU. After your shift, you talk to your co-resident and they ask why you didn’t just place a landmark based subclavian vein catheter?  You consider your question again and begin searching the literature for answers. 

PICO Question

Population: Adult patients requiring placement of a non-tunneled central venous catheter (excluding peripherally-inserted catheters).

Intervention: 1) Comparison of site selection (femoral vs. internal jugular vs. subclavian). 2) Ultrasound guidance to assist in line placement.

Comparison: 1) Comparison to the other site options. 2) Landmark-guided placement wihtout the use of ultrasound

Outcome: 1) Central line associated bloodstream infection (CLABSI), venous thrombosis, mechanical complications (pneumothorax, hematoma, arterial injury, nerve injury), patient satisfaction. 2) Success rates, time to line insertion, provider satisfaction, incidence of mechanical complications.

Article 1: Leung J, Duffy M, Finckh A. Real-time ultrasonographically-guided internal
jugular vein catheterization in the emergency department increases success rates
and reduces complications: a randomized, prospective study. Ann Emerg Med. 2006
Nov;48(5):540-7. Answer Key.

Article 2: Parienti JJ, Mongardon N, Mégarbane B, et al; 3SITES Study Group.
Intravascular Complications of Central Venous Catheterization by Insertion Site. N
Engl J Med. 2015 Sep 24;373(13):1220-9. Answer Key.

Article 3: Ge X, Cavallazzi R, Li C, Pan SM, Wang YW, Wang FL. Central venous access
sites for the prevention of venous thrombosis, stenosis and infection. Cochrane
Database Syst Rev. 2012 Mar 14;2012(3):CD004084. Answer Key.

Article 4: Arvaniti K, Lathyris D, Blot S, Apostolidou-Kiouti F, Koulenti D, Haidich AB.
Cumulative Evidence of Randomized Controlled and Observational Studies on
Catheter-Related Infection Risk of Central Venous Catheter Insertion Site in ICU
Patients: A Pairwise and Network Meta-Analysis. Crit Care Med. 2017
Apr;45(4):e437-e448. Answer Key.

Bottom Line

Over 5 million central venous catheters are placed in the Unites States every year, each carrying with it a risk not only of immediate mechanical complications from the procedure itself, but also of delayed complications, including bloodstream infections and venous thrombosis. We sought to evaluate how the choice of line insertion site (femoral, subclavian, or internal jugular) affects the risk of these complications, as well as to evaluate how the use of ultrasound guidance affects line placement success rates and immediate mechanical complications. 

We identified two systematic reviews evaluating the effects of insertion site on clinical outcomes. The first of these was a review from the Cochrane Database of Systematic Reviews (Ge 2012) which only identified four randomized controlled trials addressing this subject. There were two studies comparing internal jugular and subclavian catheters, neither of which demonstrated differences in infectious complications, thrombotic complications, or mechanical complications between the two sites. One study comparing femoral and subclavian access demonstrated higher rates of catheter colonization with femoral lines but no difference in the risk of bloodstream infections; there was a higher risk of thrombotic complications with femoral lines (RR 11.53, 95% CI 2.80 to 47.52) and no difference in immediate mechanical complications. One additional study comparing femoral and internal jugular access found no difference in infectious complications or thrombotic complications, and demonstrated a lower risk of immediate mechanical complications in the femoral line group (RR 0.51, 95% CI 0.29 to 0.88). Unfortunately, none of the included studies was conducted in the emergency department (ED); two studies only included cancer patients who needed central access for chemotherapy and one study was limited to patients requiring catheters for short-term hemodialysis (external validity). 

The second systematic review included both randomized and observational studies (Arvaniti 2017). It found a higher risk of catheter-related bloodstream infection with femoral lines compared to both internal jugular lines (RR 0.55, 95% CI 0.34 to 0.89) and subclavian lines (RR 2.44, 95% CI 1.25 to 4.75); no difference was seen between internal jugular and subclavian lines. In two studies reporting thrombotic complications, the risk was higher for femoral lines for both overall thrombosis (RR 4.58, 95% CI 1.02 to 24.52) and major thrombosis (RR 3.57, 95% CI 1.38 to 9.22). Complication rates were “rarely reported” in the included studies and hence were not included in the meta-analysis. This review was primarily limited by the pooling of results from methodologically heterogeneous observational studies and randomized controlled trials, and a high risk of selection bias in the majority of the included studies. 

The results of this systematic review differed somewhat from those of a large, multicenter, randomized controlled trial conducted in 10 ICUs in France (Parienti 2015). In this trial, the composite risk of bloodstream infection and symptomatic deep venous thrombosis was higher with femoral access compared to subclavian access (HR 3.5, 95% CI 1.5 to 7.8), but was similar to patients with internal jugular access (HR 1.3, 95% CI 0.8 to 2.1); internal jugular access was associated a higher risk of these outcomes when compared with subclavian access (HR 2.1, 95% CI 1.0 to 4.3). There were significantly fewer mechanical complications in the femoral group than the subclavian group (OR 0.3, 95% CI 0.1 to 0.8), but no differences were seen in other pairwise comparisons. 

Based on these results, it is difficult to strongly recommend one site for central line insertion over another. There does seem to be some increased risk of infectious and thrombotic complications with femoral line placement over the other two sites, but these outcomes were quite rare (occurring in 22 out of 1171 insertions in the femoral line group in the study by Parienti et al) and were balanced by a decreased risk of immediate mechanical complications. It seems most prudent to make this decision on a case-by-case basis, with additional consideration to patient discomfort and mobility (which were not assessed in any of these papers). Complicating factors such as obesity, cervical spine immobilization, and ongoing cardiopulmonary resuscitation may preclude the use of one or more sites and should also be taken into consideration. 

Finally, we reviewed an additional study comparing ultrasound-guided placement of internal jugular central venous catheters in the ED with landmark-based placement (Leung 2006). In this randomized controlled trial, successful catheter insertion (within three attempts) occurred more frequently in the ultrasound group (93.9%) than the landmark group (78.5%), with a difference of 15.4% (95% CI 3.8% to 27.0%). Complication rates were more common in the landmark group (16.9%) than the ultrasound group (4.6%), with a difference of -12.3% (95% CI -1.9% to -22.8%). Mean total insertion time did not differ between these groups, but this did not include time needed to set up the ultrasound machine. While set-up may cause ultrasound-guidance to take longer, the clear reduction in complications and increased success rate suggest that ultrasound-guidance should be used when possible for internal jugular central line placement.