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Report by Victor Ameh, Specialist Registrar
Checked by Steve Jones, Consultant in Emergency Medicine
North Western Deanery and Manchester Royal Infirmary, UK
A short cut review was carried out to establish whether the internal jugular or the subclavian approach to central venous catheterisation results in fewer complications. A systematic review, published in 2002, addressed this question. No more recent studies were found. The salient features of this review are summarised in table 11.. The clinical bottom line is that there does not appear to be any great advantage either way.
In [patients undergoing central venous catheterisation] is the [internal jugular or the subclavian approach] associated with [fewer complications]?
A 50‐year‐old man with non‐insulin dependent diabetes presents to the emergency department with a 3 day history of fever, acute confusion and lethargy. On assessment you find him in septic shock and commence peripheral fluid resuscitation. As part of the early goal directed management of this man you need to place a central venous catheter but wonder which route will be more successful and produce fewer complications.
Medline 1950 to May 2007 using the OVID interface. Cochrane database of systematic reviews: [catherisation.mp OR exp catheterization/OR exp catherization, central venous/OR central venous.mp OR central vein catheteri$.mp OR central lin$.mp] AND [(exp jugular veins/OR internal jugula$.mp) AND (exp subclavian vein/OR subclavian vein.mp)]. LIMIT to human and English language.
Altogether 561 papers were produced by searching from 1950. Once the systematic review was identified, we limited our search to publications after this date involving humans and published in English. This produced 128 papers, none of which helped answer our question.
The systematic review was well conducted but found no randomised trials to answer the question. The authors have analysed a number of prospective cohort studies that have published dichotomous results for the outcomes concerned. They found little difference between the two sites in terms of early and late complications. The authors concluded that randomised trials are required.
There appears to be no difference between the jugular and subclavian vein approaches for central vein catheterisation. In an individual patient, the approach should probably be to choose the one you have most successful experience with—although a case could be made for the opposite!