A friend of mine recently told me a story. He was told by someone that new best practice guidance was coming that the subclavian site is going to be the preferred site over the IJ. The reason for this is the decreased rate of infections at the subclavian site as compared to the IJ. I wasn’t able to verify this recommendation, but I can verify that subclavian lines have reduced rates of infection and clots. In a large, multi-center study in France, subclavian lines had a little fewer than half as many infections or clots (1.5 per 1000 catheter-days) as lines placed in the IJ (3.6 per 1000 catheter-days). And, IJ lines actually aren’t a lot better than femoral (4.6 per 1000 catheter-days). Additionally, you avoid several big problems (particularly in trauma and neuro patients) by not reducing venous drainage from the head or getting in the way of c-collars.
So, why don’t we all go for the subclavian as our first site of choice? Because we’re afraid of pneumothorax. That same French study found triple the rate of pneumothorax in subclavian lines (1.5%) as compared to IJ lines (0.5%). This is the reason we always hear for avoiding the subclavian site. But, I suspect that that pneumothorax rate is mostly related to technique. Whereas most IJ lines are placed with dynamic US guidance, most subclavian lines are placed using the old landmark technique. However, I had an attending teach me the US guided technique when I was a brand new NP and I regularly use it to place subclavian lines. Now, I still place far more IJ lines than subclavians, but I suspect that’s mostly habit.
It’s not a hard technique and I’ve had lots of success placing these lines with (so far, knock on wood) no pneumothoraces. How do you do it? Well, Josh Farkas over at PulmCrit has a great article detailing the use of US and the “shrug technique” for placing subclavian lines.
So, if the rate of infection and clots is so much lower (not to mention the other benefits) and we can reduce the rate of pneumothorax to an acceptable level, should subclavian be the site of choice? I mentioned that I wasn’t able to verify this rumor that the Best Practice guidelines were going to change, but, at least in Europe, there may be movement towards just that. The French Society of Intensive Care Medicine (SRLF), jointly with the French-Speaking Group of Paediatric Emergency Rooms and Intensive Care Units (GFRUP) and the French-Speaking Association of Paediatric Surgical Intensivists (ADARPEF) recently issued an expert consensus statement on management of intravascular catheters in the ICU. They make 2 interesting recommendations in this area: subclavian is the preferred site for central venous access, and IJ is probably not any better than femoral.
The American Society of Anesthesiologists, in Practice Guidelines for Central Venous Access 2020, cites the same data from the 2015 French study, but stops short of recommending subclavian over IJ, saying only, “in adults, select an upper body insertion site when possible to minimize the risk of infection.”
Where do you place your central lines? Do you use ultrasound? What are your thoughts on your current practice in light of this information?
critical care notes 