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Clinical question

▪ 3SITES study was a multicenter, randomized controlled trial

▪ In ICU patients was subclavian, IJ, or femoral access associated with a difference in the rate of major catheter-related complication?– Primary outcome = Major catheter-related complications from time of insertion to 48 hours post removal

▪ Bloodstream infection, CRBSI (composite)

▪ Symptomatic DVT

– Secondary safety outcome = Major mechanical complications

▪ PTX

▪ Hematoma or vessel injury

Design

▪ Hospitals in France– 10 ICU

▪ 5 community

▪ 4 academic centers

▪ 2011-2014 enrollment

▪ Intention to treat

▪ 5 day median f/up

Design

Inclusion criteria

▪ Patients >18 y.o. admitted to the ICU requiring TLC

▪ 2 or more site options– Femoral, SCV, IJV

▪ Access sites randomized– 1:1:1 ratio to available site

– 1:1 ratio with 2 available sites

Exclusion

▪ None provided

Baseline characteristics

▪ Demographics: Age 63, 64% male, BMI 26

▪ Comorbidities: T2 DM 19.7%, Cancer: 9.7%, AIDS: 1.3%; SAPS II 56.1

▪ Antibiotic therapy: 55%; anticoagulation therapy: 30%; parenteral nutrition: 6.2%

▪ Catheter insertion time quicker in femoral group (11.6 mins) vs. others (12.7 mins)

▪ Insertion failure: femoral 5.3% vs. jugular 7.7% vs. subclavian 14.7%

▪ Reason for removal: no longer needed 58%, death 18.5%, suspected catheter infection: 12%

▪ Mean duration of catheterization: 6.3 days

Line placement details

▪ Operators > 50 line experiences

▪ Aseptic procedure

▪ Seldinger technique– Landmark or ultrasound guided

– Placement technique not randomized

▪ U/S guided: subclavian (86%) vs. femoral (74%) vs. jugular (33%)

▪ Line placement confirmed

▪ Lines not to be used for blood draws or renal replacement therapy

Line removal details

▪ Catheter tip cultured upon removal with concomitant blood cultures

▪ If pt transferred from ICU with line– Blood cultures drawn at time of transfer

▪ Compressive ultrasound performed within 2 days of catheter removal

Results

▪▪ 3,027 patients included

– 3,471 catheters

▪ 1,284 IJ

▪ 1,171 Femoral

▪ 1,016 SC

▪ Baseline characteristics comparable

▪ Landmark guidance

▪ Median duration of catheter 5 days

Primary outcome results

▪ Primary Outcome (CRBSI or DVT)

▪ Femoral 22

▪ Jugular 20

▪ Subclavian 8

Secondary outcome results

▪ Secondary Outcome (major mechanical complications)

▪ Femoral 6

▪ Jugular 12– PTX=4

▪ Subclavian 18– PTX = 13

Discussion SCV catheters

LowerComplication

Higher complication

CRBSIDVTI

PTX

Criticisms

▪ Mechanical complications not primary outcome– Difficult to determine whether the SC access

reduction of DVT/CRBSI is outweighed by an increase in mechanical complications

▪ Ultrasound guidance not randomized

▪ Compression u/s may miss DVT in area of SVC around clavicle

▪ Short term analysis may not be applicable to longer stay ICU pts

▪ Chronic central-vein stenosis occurs more frequently in SCV access even for short periods and not considered