Is femoral vein central line insertion less infectious than internal jugular vein (IJV) insertion?

Femoral vs. Internal Jugular Vein Central Line Insertion: Infection Risk Comparison

Femoral vein central line insertion is NOT less infectious than internal jugular vein (IJV) insertion. According to current evidence, femoral insertion is associated with higher risks of catheter colonization and thrombotic complications compared to IJV insertion 1.

Evidence on Infection Rates by Insertion Site

Adult Patients

• The CDC 2011 guidelines recommend placing nontunneled CVCs in adults at subclavian rather than jugular or femoral sites due to infection risk 1
• Femoral vein is relatively contraindicated for parenteral nutrition due to high risk of contamination at the groin exit site 1
• Subclavian is preferable to femoral insertion for short-term catheterization because femoral insertion is associated with higher risks of catheter colonization 1

Pediatric Patients

• In children, the evidence differs somewhat from adults:
  • A large case-control study of critically ill children found no association between femoral insertion and sepsis 1
  • A cohort study of 4,512 children found no association between femoral CVC placement and greater occurrence of infection 1

Site Selection Algorithm Based on Infection Risk

1. First choice: Subclavian vein (lowest infection risk in adults)

   • Recommended by CDC guidelines for nontunneled CVCs 1
   • Associated with lower colonization rates compared to femoral sites 1

2. Second choice: Internal jugular vein

   • Lower infection risk than femoral site in adults 1
   • May be preferred when subclavian access is contraindicated

3. Third choice: Femoral vein (highest infection risk in adults)

   • Should be avoided for parenteral nutrition 1
   • Consider only when other sites are unavailable or contraindicated
   • May be acceptable in children as infection rates appear similar across sites 1

Other Considerations Beyond Infection

While infection is important, other complications should be considered when selecting a site:

• Mechanical complications:

  • Femoral CVCs have fewer mechanical complications during insertion compared to IJV 1, 2
  • Subclavian approach has higher risk of pneumothorax and hemothorax 3

• Thrombotic complications:

  • Femoral site has higher risk of venous thrombosis 1
  • A prospective study in children showed increased venous thromboembolism with femoral compared to jugular CVC 1

• Catheter maintenance:

  • Femoral sites are more difficult to dress and maintain 1
  • Tunneling onto the anterior abdominal wall can take the exit site out of the groin, facilitating access and nursing care 1

Special Situations

• Emergency situations: Femoral route may be preferred due to lower insertion complications and easier hemostasis 1
• Coagulopathy: Femoral access may be safer due to ability to apply direct pressure 1
• Tracheostomy patients: Consider avoiding jugular access 1
• Patients requiring hemodialysis: A randomized study of short-term hemodialysis catheterization reported equivalent infection risks between internal jugular and femoral access 1

Recent Evidence and Evolving Understanding

It's worth noting that the perception of femoral lines being more infectious has evolved:

• A 2012 systematic review found that while earlier studies showed higher infection rates with femoral access, more recent studies show no significant difference in catheter-related bloodstream infections between the three sites 2
• This suggests that with modern insertion techniques and catheter care, the historical difference in infection rates may be diminishing

Conclusion

When selecting a central venous access site with infection risk as the primary concern, the subclavian vein should be the first choice in adults, followed by the internal jugular vein, with the femoral vein as the last option. In children, site selection can be more flexible as infection rates appear similar across sites.