（英文原文）Intravascular Complications of Central Venous Catheterization by Insertion Site
BACKGROUND Three anatomical sites are commonly used to insert central venous catheters, but insertion at each site has the potential for major complications.
METHODS In this multicenter trial, we randomly assigned nontunneled central venous catheterization in patients in the adult intensive care unit (ICU) to the subclavian, jugular, or femoral vein (in a 1:1:1 ratio if all three insertion sites were suitable [three-choice scheme] and in a 1:1 ratio if two sites were suitable [two-choice scheme]). The primary outcome measure was a composite of catheter-related bloodstream infection and symptomatic deep-vein thrombosis.
RESULTS A total of 3471 catheters were inserted in 3027 patients. In the three-choice comparison, there were 8, 20, and 22 primary outcome events in the subclavian, jugular, and femoral groups, respectively (1.5, 3.6, and 4.6 per 1000 catheter-days; P=0.02). In pairwise comparisons, the risk of the primary outcome was significantly higher in the femoral group than in the subclavian group (hazard ratio, 3.5; 95% confidence interval [CI], 1.5 to 7.8; P=0.003) and in the jugular group than in the subclavian group (hazard ratio, 2.1; 95% CI, 1.0 to 4.3; P=0.04), whereas the risk in the femoral group was similar to that in the jugular group (hazard ratio, 1.3; 95% CI, 0.8 to 2.1; P=0.30). In the three-choice comparison, pneumothorax requiring chest-tube insertion occurred in association with 13 (1.5%) of the subclavian-vein insertions and 4 (0.5%) of the jugular-vein insertions.
CONCLUSIONS In this trial, subclavian-vein catheterization was associated with a lower risk of bloodstream infection and symptomatic thrombosis and a higher risk of pneumothorax than jugular-vein or femoral-vein catheterization.
來源：ACC News Story（September 24，2015）
【260】不同部位中心靜脈導管插入術的併發症研究（中文摘要）
近日《新英格蘭醫學雜誌》發表一項研究結果顯示，鎖骨下靜脈穿刺插管術與血液感染以及有症狀的血栓形成危險較低相關，但氣胸發生危險高於頸靜脈或股靜脈穿刺插管術。
鎖骨下靜脈、頸靜脈以及股靜脈是常被用來插入中心靜脈導管的3個解剖部位，但每個插入部位都可能引起大併發症。這項多中心試驗將在重症監護病房（ICU）接受非隧道式中心靜脈導管插入術的成年患者隨機分為3組：鎖骨下靜脈、頸靜脈和股靜脈組（若所有3種插入部位都適合就按1:1:1比例分配——3種選擇方案；若2種部位適合就按1:1比例分配——2種選擇方案）。主要轉歸指標是複合的導管相關血液感染以及有症狀的深靜脈血栓形成。
結果顯示，3027例患者共插入3471個導管。在3種選擇方案的比較中，鎖骨下靜脈、頸靜脈和股靜脈組分別發生了8、20和22個主要轉歸事件（1.5、3.6和4.6個/1000導管-天，P=0.02）。在成對比較中，股靜脈組的主要轉歸事件發生危險顯著高於鎖骨下靜脈組（HR：3.5，P=0.003），頸靜脈組顯著高於鎖骨下靜脈組（HR：2.1，P=0.04），而股靜脈組的這一危險與頸靜脈組相似（HR：1.3，P=0.30）。在3種選擇方案的比較中，鎖骨下靜脈與頸靜脈插管組的須插入胸管的氣胸事件分別為13件（1.5%）和4件（0.5%）。
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