Central Venous Line Location. Where's best?
Some of our attendings' were in a generous mood and elected to offer their time as presenters so our residents could have more time preparing for their in-service exam. This month's articles look at the topic of central line placement. Questions to be addressed include, best location for risk mitigation of infection, thrombosis, stenoses etc.. We will review a recent NEJM multi-centered RCT, a Cochrane systematic review and a systematic review and meta-analysis from two of EVMS's own clinicians. A few great video's have been posted by EmCrit and also a podcast with EVMS's own Dr. Marik. The topic should provide an opportunity to review the most current data, consider the expertise of our clinicians, their clinical biases and how patient preferences may play into technique selection. I anticipate the issue of ultrasound guided vs. landmark techniques will also come up when we consider the inter-generational knowledge gaps between the ultrasound savvy and those with extensive experience with landmark based subclavian lines who argue that many are leaving residency without having clinical confidence in non-ultrasound assisted central line techniques. Also included, is a telling article on the ubiquitous devices we cannot be without for a minute.
Marik PE, Flemmer M, The risk of catheter-related bloodstream infection with femoral venous catheters as compared to subclavian and internal jugular venous catheters: a systematic review of the literature and meta-analysis. Crit Care Med 2012 Aug;40(8):2479-85