Ver el código de «EBQ:3SITES Trial»

{{JC info
| title= Intravascular Complications of Central Venous Catheterization by Insertion Site
| abbreviation=3SITES
| expansion=
| published=2015-09-24
| author=Parienti JJ, et al
| journal=NEJM
| year=2015
| volume=373
| issue=13
| pages=1220-1229
| pmid=26398070
| fulltexturl=http://www.nejm.org/doi/full/10.1056/NEJMoa1500964
| pdfurl=http://unmhospitalist.pbworks.com/w/file/fetch/100984129/nejmoa1500964.pdf
| status=Complete
}}
==Clinical Question==
Do major complications of central venous catheters differ by site of insertion (central, subclavian and femoral)?
==Conclusion==
The subclavian site, when compared to the IJ or femoral site, is associated with fewer bloodstream infections and DVTs. The rate of mechanical complications is greatest

==Major Points== 
Central venous catheters(CVCs) are often required to establish venous access in critically ill patients in order to administer rapid [[fluid resuscitation]], [[blood products]], and [[vasopressors]].  The sites of insertion fall into three locations: Internal jugular (IJ), subclavian, and femoral.  The major [[CVC catheter problems|complications]] of concern include: catheter-related bloodstream infections (CRBI), [[DVT]], and mechanical complications (e.g. pneumothorax and arterial puncture).

The [[EBQ:3SITES Trial|3SITES Trial]] study, a multicenter randomized trial, investigated the complications of the three anatomic sites for CVC insertion in relation to blood stream infections or DVTs. Although subclavian lines appear to have a lower infection rate, there is greater incidence of mechanical complications.

==Study Design==
*Multicenter (10 ICUs from 4 university and 5 community hospitals in France) randomized, controlled trial
*N=3,471 ICU patients 
**Subclavian (n=1,016)
**Jugular (n=1,284)
**Femoral (n=1,171)
*Dates: December 2011 to June 2014
*Analysis: Intention-to-treat
*Primary outcome: Major catheter-related complications (bloodstream infection or symptomatic DVT)
*Secondary: Major mechanical complications
*Median follow up: 5 days
==Population==
===Patient Demographics===
*Age 63, 63% male, BMI 26
*Illness severity: SAPS II 57.1
*Co-morbidities: 
**Diabetes 20.5%
**Cancer 9.0%
**AIDS 1.4%
*Complicating Conditions (IJ group)
**Neutropenia (<500/mm<sup>3</sup> 1.8%
**Tracheotomy 1.7%
**Antibiotic therapy 54.1%
**Anticoagulation 30.4%
**Parenteral nutrition 5.8%

===Inclusion Criteria===
* 18 years or older
* Admitted to the ICU and required central venous access
* Had at least 2/3 acceptable insertion sites (femoral, jugular, or subclavian)

===Exclusion Criteria===
* Only one access site available


==Interventions==
*Randomization (1:1:1) to one of the three anatomic sites(subclavian, jugular, or femoral CVC) 
* Randomization stratified according to ICU and according to the use of antibiotics versus no therapy
* All ICUs used the French Haute Autorite de Sante checklist and US guidelines for preventing catheter-related infections
*Placement followed standard Seldinger technique with the use of anatomical landmarks or ultrasound guidance
*Catheter-related bloodstream infection was defined by catheter-tip colonized with the same phenotypic microorganism isolated from peripheral blood cultures
*Two days after CVCremoval ultrasound was used to detect asymptomatic or confirm symptomatic catheter-related DVT
*Sterile preparations used: 
**Alcoholic chlorhexidine 43.1%
**Alcoholic povidone-iodine 43.1%
**Aqueous povidone-iodine 9.8%
*Procedural Guidance: 
**Use of anatomical landmarks 32.7% (femoral 74%, subclavian 86%), insertion time 12.6 min, insertion failure 7.7% (subclavian 14.7%)
**Duration of catheterization 6.5 days

==Outcomes==
===Primary Outcomes===
; Catheter-related bloodstream infection or symptomatic DVT:''Femoral vs subclavian:  ''25 vs. 8 (HR 3.5; 95% CI 1.5-7.8; P=0.003)
: ''Jugular vs subclavian:  ''23 vs. 11 (HR 2.1; 95% CI 1.0-4.3; P=0.04)
: ''Femoral vs jugular:  ''33 vs. 30 (HR 1.3; 95% CI 0.8-2.1; P=0.30)

===Secondary Outcomes===
; Bloodstream infection:''Femoral vs subclavian:  ''11 vs. 4 (HR 3.4; 95% CI 1.5-7.8; P=0.048)
: ''Jugular vs subclavian:  ''13 vs. 6 (HR 2.3; 95% CI 0.8-6.2; P=0.11)
: ''Femoral vs jugular:  ''15 vs. 21 (HR 0.9; 95% CI 0.5-1.8; P=0.81)''  ''

; Symptomatic DVT:''Femoral vs subclavian:  ''15 vs. 5 (HR 3.4; 95% CI 1.5-7.8; P=0.02)
: ''Jugular vs subclavian:  ''10 vs. 6 (HR 1.8; 95% CI 0.6-4.9; P=0.29)
: ''Femoral vs jugular:  ''20 vs. 9 (HR 2.4; 95% CI 1.1-5.4; P=0.04)''  '' 

==Criticisms & Further Discussion==
*This study confirms what was demonstrated in another single site study where subclavian catheters had lower infection rates.<ref>Meta-analysis of subclavian insertion and nontunneled central venous catheter-associated infection risk reduction in critically ill adults 'Crit Care Med 2012'40(5):1627-34 [http://www.ncbi.nlm.nih.gov/pubmed/22511140 pubmed]</ref>
*High risk patients may have been excluded from the subclavian site.
*Crash line complications and infections cannot be extrapolated from this data
*Mechanical complications were a secondary outcome and reduction in infections may not be outweighted by the risk of mechanical complications in some settings.
*The the study was ICU based and "crash lines" in the ER cannot be abstracted from this population.
*Ultrasound guidance was not randomized and use may affect results positively or negatively.
==External Links==
[http://rebelem.com/november-2015-rebelcast-all-vascular-access-episode/ RebelEM Podcast - Vascular Access]
==See Also==
*[[Central venous catheterization]]
==Funding==
*Grant from the Hospital Program for Clinical Research, French Ministry of Health
==References==
<references/>

[[Category:EBQ]]