Beruflich Dokumente
Kultur Dokumente
454
METHODS
Search Strategy. An extensive search of
the relevant literature without restriction to
the English language was carried out using
lyzed. Abstracts of all potentially relevant reports were screened by two authors (SR and
BW). Papers that did not clearly meet the
inclusion criteria were excluded at this stage.
From included studies, dichotomous data on
complications per insertion site were extracted as reported by the original authors.
Data on patients, clinical settings, and operators were extracted from each included study.
Data abstraction was carried out by one investigator (SR) and cross-checked by the two others.
Validity Assessment. There was an intention to include data from randomized trials
only. However, our search strategies did not
retrieve one single randomized trial that was
relevant for the purpose of our study (i.e., in
which patients were randomly allocated to one
of the two CVC accesses). In clinical studies
that are not properly randomized, there is a
risk of selection bias; selection bias may lead
to overestimation of the effect of a treatment
(6). Another frequent problem with nonrandomized studies is unequal group sizes. This
may happen when trialists have a free choice
of what intervention to use, and when for
external reasons (e.g., institutional policies)
one intervention is systematically used more
often compared with another. Undue weight
would then be given to the intervention that is
used more often. We assume that the magnitude of inequality between group sizes in a
comparative but nonrandomized trial to some
extent reflects the degree of selection bias in
that trial. Thus, to minimize the risk of selection bias, we excluded trials from further analyses when their group sizes differed more than
twofold. Finally, we excluded trials with retrospective data collection, inasmuch as those are
prone to observational bias and because data
selection cannot be ruled out.
Meta-analyses. Dichotomous data on complications per number of inserted CVCs were
analyzed. We calculated relative risks (RR)
with 95% confidence intervals (CI) (RevMan
version 4.0, Cochrane Library, Oxford, UK).
We used the fixed-effect model when the data
were homogeneous (p .1) and, otherwise, a
random effects model. As an estimate of the
clinical relevance of any difference between
the two CVC accesses, we calculated the number-needed-to-treat (7). The number-neededto-treat indicated how many catheters had to
be inserted by one route for one catheter to
lead to a complication that would not have
happened had the other approach been chosen. A positive number-needed-to-treat indicated that the end point happened more often
with the jugular approach. A negative number-needed-to-treat indicated the opposite.
RESULTS
Retrieved Reports. We screened 747
reports (Fig. 1). Of the 35 potentially relevant trials, 4 were excluded because data
on complications were lacking (8 11),
and 7 because the insertion site was unCrit Care Med 2002 Vol. 30, No. 2
DISCUSSION
In many institutions, the anatomical
site of CVC insertion is chosen on the
grounds of personal experience or local
policies rather than on evidence-based
guidelines. The aim of this quantitative
systematic review was to clarify some of
the controversies that exist on the relative risk of internal jugular compared
455
Jug
Subcl
Catheter Type
52
63
201
179
248
286
CVC
306
352
118
87
52
290
56
65
62
498
94
37
230
176
58
50
107
44
76
114
50
107
194
50
101
72
18
19
Setting
Operator
ICU fellows
Oncology
Abdominal surgery
Multidisciplinary ICU
Community teaching hospital
Main author
Unknown
Residents
Surgical, medical, or
anesthesia residents
Residents or 4th-year
medical students
Anesthesiologist
Residents
Treating physician
Unknown
Unknown
Nephrology medical
staff
House officers in
training
ICU fellows or
residents
Jug, jugular; Subcl, subclavian; CVC, central venous catheter; Fr, French; ICU, intensive care unit; PAC, pulmonary artery catheter; G, gauge.
Figure 2. Relative risk (RR) of arterial puncture with jugular vs. subclavian access. n, number with arterial puncture; N, number of catheters; 95% CI Fixed,
95% confidence interval, fixed effect model.
with subclavian access. If there was evidence for an increased risk of specific
complications with one approach, then
clinicians may take advantage of that
knowledge for insertion of a CVC in an
individual patient.
456
Figure 3. Relative risk (RR) of catheter malposition with jugular vs. subclavian access. n, number with catheter malpositions; N, number of catheters; 95%
CI Fixed, 95% confidence interval, fixed effect model.
Figure 4. Relative risk (RR) of bloodstream infection with jugular vs. subclavian access. n, number with bloodstream infection; N, number of catheters; 95%
CI Random, 95% confidence interval, a random effects model.
Figure 5. Relative risk (RR) of hemato- or pneumothorax with jugular vs. subclavian access. n, number with hemato- or pneumothorax; N, number of
catheters; 95% CI Fixed, 95% confidence interval, fixed effect model.
these trials. However, there was no evidence that this potential underreporting
would have favored one approach compared with the other. Consequently, these
data are likely to represent a best case
scenario in terms of risk assessment for
both CVC accesses.
457
CONCLUSIONS
These data from nonrandomized clinical trials are likely to reflect a best case
scenario in terms of risk assessment.
There is some evidence that there are
more arterial punctures but less catheter
malpositions with the internal jugular
compared with the subclavian access.
There is no evidence of any difference in
the incidence of hemato- or pneumothorax and vessel occlusion. Bloodstream infection happened more often with the internal jugular access, but the data were
heterogeneous and there was no evidence
of statistical significance. The lack of randomized comparisons of jugular and sub-
Figure 6. Relative risk (RR) of vessel occlusion with jugular vs. subclavian access. n, number with vessel occlusion; N, number of catheters; 95% CI Fixed,
95% confidence interval, fixed effect model.
458
ACKNOWLEDGMENTS
We thank Daniel Haake from the Documentation Service of the Swiss Academy
of Medical Sciences for his help in searching electronic databases.
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