For patients in intensive care units who need a catheter so they can receive medications easily, one placed in the vein under the collarbone appears to lower the risk of bloodstream infections and clots, a new study finds.
The researchers reported that it lowered those risks by two to three times when compared to catheters placed in the large vein in the groin or in the jugular vein in the neck.
"There has been an ongoing controversy about where to place these large catheters that would have the least risk of life-threatening infections," said senior researcher Dr. Leonard Mermel, from Lifespan in Providence, R.I.
These infections are usually caused by bacteria on the skin that cling to the catheter as it is inserted and find their way into the bloodstream, he explained. In this setting, a catheter is a long tube that is inserted into the body so medicines can be delivered to the patient easily.
The one drawback to inserting a catheter into the vein under the collarbone is the risk for causing a collapsed lung. This can occur if the catheter misses the vein and punctures a lung as it is inserted, Mermel said.
In this study, 1.5 percent of patients having a catheter placed under the collarbone suffered a collapsed lung, as did 0.5 percent of patients who had a catheter placed in the neck, the researchers found.
Mermel said that although placing a catheter in the vein under the collarbone is preferred, a lot depends on how well the person placing the catheter has been trained. Using ultrasound to guide the placement of the catheter is one way of avoiding complications such as a collapsed lung, he added.
Lead researcher Dr. Jean-Jacques Parienti, from the department of biostatistics and clinical research at Cote de Nacre University Hospital in Caen, France, said, "The [under the collarbone] route is the safest for the patient, provided that everything is done to reduce the risk of mechanical complications during insertion."
The report was published Sept. 24 in the New England Journal of Medicine.
Dr. Mark Astiz, chairman of medicine at Lenox Hill Hospital in New York City, said the new study was "consistent with earlier reports and suggests if the operator is well trained in [under the collarbone] catheter placement, that may be the preferred site."
For the study, researchers randomly assigned more than 3,000 patients to have catheters placed in one of the three locations.
Dr. Anthony Rossi, director of the division of cardiac critical care medicine at Nicklaus Children's Hospital in Miami, said bloodstream infections are less likely when a catheter is placed in the vein under the collarbone because the skin at the collarbone has less bacteria than either the neck or the groin.
In addition, catheters under the collarbone can be secured more easily than in the neck or groin because there is less movement in the chest than in those other areas. This makes it easier to keep those catheters cleaner, Rossi said.
"Anything we can do to prevent bloodstream infections is important," he said. "Most people don't die from a [collapsed lung], but the mortality from a bloodstream infection can be 40 percent or more, and they are hard to treat in the critically ill."
